Healthcare Provider Details

I. General information

NPI: 1023298403
Provider Name (Legal Business Name): PHOENIX WELLNESS CENTERS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2007
Last Update Date: 06/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 E EIGHTH ST
TRAVERSE CITY MI
49686-2938
US

IV. Provider business mailing address

1203 E EIGHTH ST
TRAVERSE CITY MI
49686-2938
US

V. Phone/Fax

Practice location:
  • Phone: 231-938-8000
  • Fax: 231-938-0547
Mailing address:
  • Phone: 231-938-8000
  • Fax: 231-938-0547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number2301007576
License Number StateMI

VIII. Authorized Official

Name: DR. CHARLES HOWARD LANGE
Title or Position: PRESIDENT
Credential: D.C
Phone: 231-938-8000