=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881854164
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPECIALIZED FAMILY CHIROPRACTIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2008
-----------------------------------------------------
Last Update Date | 09/21/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8150 MOORSBRIDGE RD SUITE B
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-323-4473
-----------------------------------------------------
Fax | 269-324-0755
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8150 MOORSBRIDGE RD SUITE B
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-324-4143
-----------------------------------------------------
Fax | 269-324-0755
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | STEVEN T OSTERHOUT
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 269-324-4143
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 111NN1001X
-----------------------------------------------------
Taxonomy Name | Nutrition Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------