Provider Demographics
NPI:1912247743
Name:JIVANTA CHIROPRACTIC WELLNESS CENTRE PLLC
Entity Type:Organization
Organization Name:JIVANTA CHIROPRACTIC WELLNESS CENTRE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:PLUHAR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:231-941-8808
Mailing Address - Street 1:1235 WOODMERE AVE
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-4249
Mailing Address - Country:US
Mailing Address - Phone:231-941-8808
Mailing Address - Fax:231-941-8690
Practice Address - Street 1:1235 WOODMERE AVE
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-4249
Practice Address - Country:US
Practice Address - Phone:231-941-8808
Practice Address - Fax:231-941-8690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-14
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005809111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU25907Medicare UPIN
MI0B85031Medicare PIN