Provider Demographics
NPI:1982966511
Name:COMMUNITY CHIROPRACTIC HEALTH CENTER, P.C.
Entity Type:Organization
Organization Name:COMMUNITY CHIROPRACTIC HEALTH CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:LEBLANC
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:231-256-7877
Mailing Address - Street 1:PO BOX 232
Mailing Address - Street 2:489 W MAIN ST
Mailing Address - City:LAKE LEELANAU
Mailing Address - State:MI
Mailing Address - Zip Code:49653-0232
Mailing Address - Country:US
Mailing Address - Phone:231-256-7877
Mailing Address - Fax:231-256-9529
Practice Address - Street 1:489 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE LEELANAU
Practice Address - State:MI
Practice Address - Zip Code:49653-9740
Practice Address - Country:US
Practice Address - Phone:231-256-7877
Practice Address - Fax:231-256-9529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006832111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2694706Medicaid
MI2694706Medicaid