Provider Demographics
NPI:1649330416
Name:EAST STADIUM CHIROPRACTIC WELLNESS CENTER LLC
Entity type:Organization
Organization Name:EAST STADIUM CHIROPRACTIC WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:KROES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:734-971-1777
Mailing Address - Street 1:2216 MEDFORD RD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-5059
Mailing Address - Country:US
Mailing Address - Phone:734-971-1777
Mailing Address - Fax:
Practice Address - Street 1:2216 MEDFORD RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-5059
Practice Address - Country:US
Practice Address - Phone:734-971-1777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAB009521111N00000X
MIBK004737111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950H150720Medicare ID - Type Unspecified
MIH15072005Medicare PIN
MI950H151170Medicare ID - Type Unspecified