Healthcare Provider Details

I. General information

NPI: 1871777235
Provider Name (Legal Business Name): MICHIGAN SPINE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2007
Last Update Date: 12/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30325 GRATIOT AVE
ROSEVILLE MI
48066-1714
US

IV. Provider business mailing address

30325 GRATIOT AVE
ROSEVILLE MI
48066-1714
US

V. Phone/Fax

Practice location:
  • Phone: 586-774-6301
  • Fax:
Mailing address:
  • Phone: 586-774-6301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number2301009010
License Number StateMI

VIII. Authorized Official

Name: DR. JASON A STANCZAK
Title or Position: OWNER
Credential: D,C,
Phone: 586-774-6301