Provider Demographics
NPI:1861972309
Name:FETTERLY, DOMINIC (DC)
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:FETTERLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S SHORE DR UNIT 121
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49014-5440
Mailing Address - Country:US
Mailing Address - Phone:269-963-3072
Mailing Address - Fax:
Practice Address - Street 1:601 S SHORE DR UNIT 121
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49014-5440
Practice Address - Country:US
Practice Address - Phone:269-963-3072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010700111NN0400X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NN0400XChiropractic ProvidersChiropractorNeurology