Provider Demographics
NPI:1639411465
Name:4TH STREET CHIROPRACTIC INC
Entity Type:Organization
Organization Name:4TH STREET CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:VALLECORSE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-841-1785
Mailing Address - Street 1:117 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-2025
Mailing Address - Country:US
Mailing Address - Phone:248-841-1785
Mailing Address - Fax:
Practice Address - Street 1:117 W 4TH ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-2025
Practice Address - Country:US
Practice Address - Phone:248-841-1785
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010018111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty