Provider Demographics
NPI:1902176597
Name:SOUTHWEST SPINE CENTER PLLC
Entity Type:Organization
Organization Name:SOUTHWEST SPINE CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:AWWAD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:269-432-9595
Mailing Address - Street 1:26421 SOUTHFIELD ROAD
Mailing Address - Street 2:
Mailing Address - City:LATHRUP VILLAGE
Mailing Address - State:MI
Mailing Address - Zip Code:48076
Mailing Address - Country:US
Mailing Address - Phone:249-805-5066
Mailing Address - Fax:249-905-5069
Practice Address - Street 1:521 N BURR OAK RD
Practice Address - Street 2:
Practice Address - City:COLON
Practice Address - State:MI
Practice Address - Zip Code:49040-9403
Practice Address - Country:US
Practice Address - Phone:269-432-9595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty