=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821047861
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VAN BORN CHIROPRACTIC CLINIC, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2006
-----------------------------------------------------
Last Update Date | 02/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23610 VAN BORN RD
-----------------------------------------------------
City | DEARBORN HEIGHTS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48125-2356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-291-1060
-----------------------------------------------------
Fax | 313-291-1089
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23610 VAN BORN RD
-----------------------------------------------------
City | DEARBORN HEIGHTS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48125-2356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-291-1060
-----------------------------------------------------
Fax | 313-291-1089
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | RENEE IRENE PETHTEL
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 313-291-1060
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------