Provider Demographics
NPI:1730209479
Name:A FAMILY CHIROPRACTIC CENTER, PC
Entity type:Organization
Organization Name:A FAMILY CHIROPRACTIC CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:574-255-1716
Mailing Address - Street 1:535 LINCOLN WAY W
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-1800
Mailing Address - Country:US
Mailing Address - Phone:574-255-1716
Mailing Address - Fax:574-255-5379
Practice Address - Street 1:535 LINCOLN WAY W
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-1800
Practice Address - Country:US
Practice Address - Phone:574-255-1716
Practice Address - Fax:574-255-5379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN51000342A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000202168Medicare UPIN
IN180170Medicare ID - Type Unspecified