Provider Demographics
NPI:1720319569
Name:WELLNESS CHIROPRACTIC P.C.
Entity Type:Organization
Organization Name:WELLNESS CHIROPRACTIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIRIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MIKHALOV
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-225-4351
Mailing Address - Street 1:5380 E GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-9101
Mailing Address - Country:US
Mailing Address - Phone:248-225-4351
Mailing Address - Fax:
Practice Address - Street 1:6691 BROOKESHIRE DR
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-2725
Practice Address - Country:US
Practice Address - Phone:248-225-4351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-19
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008158111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N20600Medicare PIN