Provider Demographics
NPI:1922057603
Name:MCNINCH, CHARLES JAMES (DC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JAMES
Last Name:MCNINCH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 N LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-1132
Mailing Address - Country:US
Mailing Address - Phone:616-754-4621
Mailing Address - Fax:616-754-4679
Practice Address - Street 1:1100 N LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-1132
Practice Address - Country:US
Practice Address - Phone:616-754-4621
Practice Address - Fax:616-754-4679
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007870111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI010555581OtherPPOM
MI950E910200OtherBLUE CROSS BLUE SHIELD
MI4374626Medicaid
MI010555581OtherPPOM
0N40910Medicare ID - Type Unspecified