Provider Demographics
NPI:1780049528
Name:PEACOCK FAMILY CHIROPRACTIC, PLLC
Entity type:Organization
Organization Name:PEACOCK FAMILY CHIROPRACTIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:JOEL
Authorized Official - Last Name:PEACOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:989-734-3384
Mailing Address - Street 1:408 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49779-1309
Mailing Address - Country:US
Mailing Address - Phone:989-734-3384
Mailing Address - Fax:989-734-7391
Practice Address - Street 1:408 N 3RD ST
Practice Address - Street 2:
Practice Address - City:ROGERS CITY
Practice Address - State:MI
Practice Address - Zip Code:49779-1309
Practice Address - Country:US
Practice Address - Phone:989-734-3384
Practice Address - Fax:989-734-7391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-21
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010287111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1790174556Medicaid
MI1790174456Medicare PIN