Provider Demographics
NPI:1871687814
Name:PROGRESSIVE CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:PROGRESSIVE CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRGICAK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-544-9009
Mailing Address - Street 1:716 W. 11 MILE RD.
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067
Mailing Address - Country:US
Mailing Address - Phone:248-544-9009
Mailing Address - Fax:248-544-9002
Practice Address - Street 1:716 W. 11 MILE RD.
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067
Practice Address - Country:US
Practice Address - Phone:248-544-9009
Practice Address - Fax:248-544-9002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008248111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950F325960Medicare UPIN
MI0P17440Medicare ID - Type UnspecifiedMEDICARE
MI0P17440Medicare PIN