Healthcare Provider Details

I. General information

NPI: 1144316266
Provider Name (Legal Business Name): EDGERTON CHIROPRACTIC CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 06/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7616 BROCKWAY RD
BROCKWAY MI
48097-3408
US

IV. Provider business mailing address

7616 BROCKWAY RD
BROCKWAY MI
48097-3408
US

V. Phone/Fax

Practice location:
  • Phone: 810-387-3342
  • Fax: 810-387-3543
Mailing address:
  • Phone: 810-387-3342
  • Fax: 810-387-3543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberBE006504
License Number StateMI

VIII. Authorized Official

Name: DR. BRENT LEE EDGERTON
Title or Position: PRESIDENT
Credential: DC
Phone: 810-387-3342