Provider Demographics
NPI:1942441803
Name:JEFFERY SCOTT CARPENTER, D.C., P.L.L.C.
Entity Type:Organization
Organization Name:JEFFERY SCOTT CARPENTER, D.C., P.L.L.C.
Other - Org Name:CARPENTER CHIROPRACTIC & WELLNESS CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:RECEPTIONIST/BILLING
Authorized Official - Prefix:MS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:NIEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-966-1600
Mailing Address - Street 1:1530 PINE GROVE AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3370
Mailing Address - Country:US
Mailing Address - Phone:810-966-1600
Mailing Address - Fax:810-966-1601
Practice Address - Street 1:1530 PINE GROVE AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3370
Practice Address - Country:US
Practice Address - Phone:810-966-1600
Practice Address - Fax:810-966-1601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-23
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008269111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4330935Medicaid
0N32310Medicare PIN