Provider Demographics
NPI:1619059383
Name:MAIN STREET FAMILY CHIROPRACTIC CENTER, P.C.
Entity type:Organization
Organization Name:MAIN STREET FAMILY CHIROPRACTIC CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:STANLEY
Authorized Official - Last Name:STOPA
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:248-735-9800
Mailing Address - Street 1:109 W MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167
Mailing Address - Country:US
Mailing Address - Phone:248-735-9800
Mailing Address - Fax:248-735-9801
Practice Address - Street 1:109 W MAIN STREET
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167
Practice Address - Country:US
Practice Address - Phone:248-735-9800
Practice Address - Fax:248-735-9801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007768111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950H253850OtherBCBS
MI950H253850OtherBCBS
0M90630Medicare Oscar/Certification
U76357Medicare UPIN