Provider Demographics
NPI:1043408149
Name:FULL POTENTIAL CHIROPRACTIC, PC
Entity type:Organization
Organization Name:FULL POTENTIAL CHIROPRACTIC, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:ANGELO
Authorized Official - Last Name:HOUSE
Authorized Official - Suffix:II
Authorized Official - Credentials:DC
Authorized Official - Phone:269-792-9952
Mailing Address - Street 1:135 E SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49348-1137
Mailing Address - Country:US
Mailing Address - Phone:269-792-9952
Mailing Address - Fax:269-792-6459
Practice Address - Street 1:135 E SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MI
Practice Address - Zip Code:49348-1137
Practice Address - Country:US
Practice Address - Phone:269-792-9952
Practice Address - Fax:269-792-6459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI007970111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI14-4473043Medicaid
MI0N55100Medicare PIN