Provider Demographics
NPI:1629273743
Name:WEST BRANCH CHIROPRACTIC CENTER, PC
Entity Type:Organization
Organization Name:WEST BRANCH CHIROPRACTIC CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DREW
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARENTETTE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:989-345-3310
Mailing Address - Street 1:110 E HOUGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661-1124
Mailing Address - Country:US
Mailing Address - Phone:989-345-3310
Mailing Address - Fax:989-345-6610
Practice Address - Street 1:110 E HOUGHTON AVE
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661-1124
Practice Address - Country:US
Practice Address - Phone:989-345-3310
Practice Address - Fax:989-345-6610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDM007681111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950F510500OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI950F55000OtherBLUE CROSS BLUE SHIELD MI
MI950F510500OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI0N90900Medicare ID - Type Unspecified