Provider Demographics
NPI:1144316266
Name:EDGERTON CHIROPRACTIC CLINIC INC
Entity type:Organization
Organization Name:EDGERTON CHIROPRACTIC CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:EDGERTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:810-387-3342
Mailing Address - Street 1:7616 BROCKWAY RD
Mailing Address - Street 2:
Mailing Address - City:BROCKWAY
Mailing Address - State:MI
Mailing Address - Zip Code:48097-3408
Mailing Address - Country:US
Mailing Address - Phone:810-387-3342
Mailing Address - Fax:810-387-3543
Practice Address - Street 1:7616 BROCKWAY RD
Practice Address - Street 2:
Practice Address - City:BROCKWAY
Practice Address - State:MI
Practice Address - Zip Code:48097-3408
Practice Address - Country:US
Practice Address - Phone:810-387-3342
Practice Address - Fax:810-387-3543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBE006504111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950G411160OtherBCBS
MI950G411160OtherBCBS