Healthcare Provider Details

I. General information

NPI: 1073542858
Provider Name (Legal Business Name): ERNEST RICHARD CENTOFANTI D.C., C.C.S.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3078 MAIN ST
MARLETTE MI
48453-0245
US

IV. Provider business mailing address

3078 MAIN ST PO BOX 245
MARLETTE MI
48453-1292
US

V. Phone/Fax

Practice location:
  • Phone: 989-635-3828
  • Fax: 989-635-3828
Mailing address:
  • Phone: 989-635-3828
  • Fax: 989-635-3828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number005491
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: