MEDICARE: JETTIE CHIROPRACTIC CENTER P.C.

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	111N00000X	Chiropractor	RJ004377	MI

General Provider Information

NPI Number	:	1285947093
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JETTIE CHIROPRACTIC CENTER P.C.

Provider Business Mailing Address
First Line	:	30405 W 12 MILE RD
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48334-3805
Country	:	US
Telephone Number	:	248-477-5255
Fax Number	:	248-474-4383

Provider Business Practice Location Address
First Line	:	30405 W 12 MILE RD
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48334-3805
Country	:	US
Telephone Number	:	248-477-5255
Fax Number	:	248-474-4383

Authorized Official
Title or Position	:	DOCTOR OF CHIROPRACTIC
Name	:	DR. RONALD C JETTIE
Credential	:	D.C.
Telephone Number	:	248-477-5255

Provider Enumeration Date	:	07/21/2010
Last Update Date	:	07/21/2010

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