Healthcare Provider Details

I. General information

NPI: 1881873651
Provider Name (Legal Business Name): ABC BACK & NECK CARE OF WATERFORD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2007
Last Update Date: 10/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5663 HIGHLAND RD
WATERFORD MI
48327-1972
US

IV. Provider business mailing address

3283 W SILVER LAKE RD
FENTON MI
48430-1369
US

V. Phone/Fax

Practice location:
  • Phone: 124-867-4312
  • Fax:
Mailing address:
  • Phone: 810-750-0222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0200X
TaxonomyRadiology Chiropractor
License Number2301007718
License Number StateMI

VIII. Authorized Official

Name: TIMOTHY J SUSZKO
Title or Position: PRESIDENT
Credential: DC
Phone: 810-750-0222