MEDICARE: SCOTT R JETTIE DC 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	111N00000X	Chiropractor	2301009794	MI

General Provider Information

NPI Number	:	1295179026
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SCOTT R JETTIE DC LLC

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	:	CHIROPRACTOR
Name	:	SCOTT RONALD JETTIE
Credential	:	D.C.
Telephone Number	:	248-477-5255

Provider Enumeration Date	:	04/23/2013
Last Update Date	:	04/23/2013

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