Provider Demographics
NPI:1821047861
Name:VAN BORN CHIROPRACTIC CLINIC, P.C.
Entity Type:Organization
Organization Name:VAN BORN CHIROPRACTIC CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:PETHTEL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:313-291-1060
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0Q24591OtherBCBC MI GROUP ID
MIQ24591Medicare UPIN
MI0Q24591OtherBCBC MI GROUP ID