Provider Demographics
NPI:1881873651
Name:ABC BACK & NECK CARE OF WATERFORD
Entity type:Organization
Organization Name:ABC BACK & NECK CARE OF WATERFORD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SUSZKO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:810-750-0222
Mailing Address - Street 1:3283 W SILVER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-1369
Mailing Address - Country:US
Mailing Address - Phone:810-750-0222
Mailing Address - Fax:
Practice Address - Street 1:5663 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1972
Practice Address - Country:US
Practice Address - Phone:124-867-4312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ABC BACK & NECK CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007718111NR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0200XChiropractic ProvidersChiropractorRadiologyGroup - Single Specialty