Provider Demographics
NPI:1760431977
Name:PETHTEL, RENEE IRENE (DC)
Entity Type:Individual
Prefix:DR
First Name:RENEE
Middle Name:IRENE
Last Name:PETHTEL
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23610 VAN BORN RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48125-2356
Mailing Address - Country:US
Mailing Address - Phone:313-291-1060
Mailing Address - Fax:313-291-1089
Practice Address - Street 1:23610 VAN BORN RD
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48125-2356
Practice Address - Country:US
Practice Address - Phone:313-291-1060
Practice Address - Fax:313-291-1089
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007287111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3264700Medicaid
MI950H253460OtherBCBS PPO
MI140343OtherPREFERRED CHOICES
MIP101064OtherBLUECARE NETWORK
MI11285842OtherCAQH
MIRP007287OtherBCBS ID
MIU61953OtherHAP
MIP101064OtherBLUECARE NETWORK
MI3264700Medicaid