MEDICARE: SPINE AND WELLNESS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center	2301010613	MI

General Provider Information

NPI Number	:	1154839231
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPINE AND WELLNESS LLC

Provider Business Mailing Address
First Line	:	39880 VAN DYKE AVE STE 201
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48313-4670
Country	:	US
Telephone Number	:	586-745-1021
Fax Number	:

Provider Business Practice Location Address
First Line	:	39880 VAN DYKE AVE STE 201
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48313-4670
Country	:	US
Telephone Number	:	586-745-1021
Fax Number	:

Authorized Official
Title or Position	:	OWNER/CHIROPRACTOR
Name	:	DR. BRADLEY BURGESS
Credential	:	DC
Telephone Number	:	586-556-1060

Provider Enumeration Date	:	01/11/2018
Last Update Date	:	01/11/2018

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Directions to “SPINE AND WELLNESS LLC ” Practice Location

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