Provider Demographics
NPI:1851562409
Name:BACK TO HEALTH CHIROPRACTIC - PORTAGE PC
Entity Type:Organization
Organization Name:BACK TO HEALTH CHIROPRACTIC - PORTAGE PC
Other - Org Name:PORTAGE FAMILY CHRIOPRACTIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHEUNEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:269-345-2273
Mailing Address - Street 1:1930 W MILHAM AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-2228
Mailing Address - Country:US
Mailing Address - Phone:269-345-2273
Mailing Address - Fax:269-345-2090
Practice Address - Street 1:1930 W MILHAM AVE
Practice Address - Street 2:SUITE D
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-2228
Practice Address - Country:US
Practice Address - Phone:269-345-2273
Practice Address - Fax:269-345-2090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-21
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4344547Medicaid
MI4344547Medicaid