Provider Demographics
NPI:1801378971
Name:TENNISWOOD CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:TENNISWOOD CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:GAIL
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-764-5305
Mailing Address - Street 1:4010 PAGE AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49254-1026
Mailing Address - Country:US
Mailing Address - Phone:151-776-4530
Mailing Address - Fax:517-764-5417
Practice Address - Street 1:4010 PAGE AVE STE 104
Practice Address - Street 2:
Practice Address - City:MICHIGAN CENTER
Practice Address - State:MI
Practice Address - Zip Code:49254-1026
Practice Address - Country:US
Practice Address - Phone:151-776-4530
Practice Address - Fax:517-764-5417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010392111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty