Provider Demographics
NPI:1902999626
Name:REDFORD CHIROPRACTIC CENTER PC
Entity Type:Organization
Organization Name:REDFORD CHIROPRACTIC CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:S
Authorized Official - Last Name:CROMARTY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:313-387-8122
Mailing Address - Street 1:24801 FIVE MILE ROAD
Mailing Address - Street 2:SUITE #22
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239
Mailing Address - Country:US
Mailing Address - Phone:313-387-8122
Mailing Address - Fax:313-387-8123
Practice Address - Street 1:24801 FIVE MILE ROAD
Practice Address - Street 2:SUITE #22
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239
Practice Address - Country:US
Practice Address - Phone:313-387-8122
Practice Address - Fax:313-387-8123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005184111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN83130Medicare ID - Type UnspecifiedMEDICARE