Healthcare Provider Details

I. General information

NPI: 1295312007
Provider Name (Legal Business Name): OPTIMUM HEALTH CHIROPRACTIC CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 03/26/2021
Certification Date: 03/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5833 OAKLAND DR
PORTAGE MI
49024-1163
US

IV. Provider business mailing address

5833 OAKLAND DR
PORTAGE MI
49024-1163
US

V. Phone/Fax

Practice location:
  • Phone: 269-344-4057
  • Fax: 269-344-5473
Mailing address:
  • Phone: 269-344-4057
  • Fax: 269-344-5473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: CRAIG STULL
Title or Position: CHIROPRACTOR/OWNER
Credential: D.C.
Phone: 269-217-4513