Healthcare Provider Details

I. General information

NPI: 1447212600
Provider Name (Legal Business Name): CHARLES BRYAN STROTHER DC FICPA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 07/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 W MADISON AVE
NEW BUFFALO MI
49117-1734
US

IV. Provider business mailing address

1 W MADISON AVE
NEW BUFFALO MI
49117-1734
US

V. Phone/Fax

Practice location:
  • Phone: 269-469-1310
  • Fax: 269-469-3969
Mailing address:
  • Phone: 269-469-1310
  • Fax: 269-469-3969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCS007584
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number08002381A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: