=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073044244
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATLANTIC SPORTS & FAMILY WELLNESS CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2017
-----------------------------------------------------
Last Update Date | 03/21/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 905 W EISENHOWER CIR SUITE 108
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48103-6400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 647-464-0211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 905 W EISENHOWER CIR SUITE 108
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48103-6400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 647-464-0211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SEAN EASTMAN
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 647-464-0211
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2301010417
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------