Provider Demographics
NPI:1649305673
Name:PETSCH CHIROPRACTIC CENTER PC
Entity type:Organization
Organization Name:PETSCH CHIROPRACTIC CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:PETSCH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:231-894-2900
Mailing Address - Street 1:104 W COLBY ST
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49461-2005
Mailing Address - Country:US
Mailing Address - Phone:231-894-2900
Mailing Address - Fax:231-893-1144
Practice Address - Street 1:104 W COLBY ST
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:MI
Practice Address - Zip Code:49461-2005
Practice Address - Country:US
Practice Address - Phone:231-894-2900
Practice Address - Fax:231-893-1144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006906111N00000X
MI2301400102111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
N98920002Medicare ID - Type Unspecified
MIN98920001Medicare ID - Type Unspecified