Provider Demographics
NPI:1801098256
Name:FULLY ALIVE FAMILY CHIROPRACTIC
Entity type:Organization
Organization Name:FULLY ALIVE FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL CHIROPRACTIC ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:BROOK
Authorized Official - Middle Name:
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:268-556-9654
Mailing Address - Street 1:2600 LINCOLN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-3305
Mailing Address - Country:US
Mailing Address - Phone:269-556-9654
Mailing Address - Fax:269-556-9735
Practice Address - Street 1:2600 LINCOLN AVE STE A
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085
Practice Address - Country:US
Practice Address - Phone:269-556-9654
Practice Address - Fax:269-556-9735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITC009168111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P50080Medicare PIN