Provider Demographics
NPI:1790958627
Name:OPTIMAL WELLNESS FAMILY CHIROPRACTIC, INC
Entity Type:Organization
Organization Name:OPTIMAL WELLNESS FAMILY CHIROPRACTIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGMANN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-792-6570
Mailing Address - Street 1:3302 CROOKS RD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-2446
Mailing Address - Country:US
Mailing Address - Phone:248-629-6071
Mailing Address - Fax:248-629-6071
Practice Address - Street 1:3302 CROOKS RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-2446
Practice Address - Country:US
Practice Address - Phone:248-629-6071
Practice Address - Fax:248-629-6071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-11
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009334111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP56370OtherMEDICARE PTAN