Waters Edge Chiropractic PLC
Organization Active NPI Clinic/Center · Gladstone, MI
NPI 1396916482 · NPPES record last updated Mar 17, 2021
Key facts
- NPI
- 1396916482
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Clinic/Center 261Q00000X
- License
- 2301009453 (MI)
- Legal business name
- WATERS EDGE CHIROPRACTIC PLC
- Practice address
- 922 Delta Ave
Gladstone, MI 49837-1649 - Phone
- (906) 428-9076
- NPI assigned
- Mar 17, 2008
- Organization subpart
- No
Authorized official
- Name
- Dr. Patrick Dean Johnson, D.C.
- Title
- Ceo
- Phone
- (906) 399-2800
Practitioners 1
-
Patrick Dean Johnson, D.C.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MI
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20080905000630 | MI | Part B Supplier - Clinic/Group Practice | 9032285804 |
Receives reassigned benefits from 1 practitioner Practice locations: Gladstone, MI |
National Provider Directory
Locations
1010 Delta Ave
Ste 216
Gladstone, MI 49837
Phone (906) 428-9076
922 Delta Ave
Gladstone, MI 49837
Phone (906) 399-2800
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinic/Center | 261Q00000X | 2301009453 | MI | Yes |
Addresses
Primary practice location
922 Delta Ave
Gladstone, MI 49837-1649
Mailing address
1010 Delta Ave Ste 216
Gladstone, MI 49837-1522
Phone (906) 428-9076
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1200009 | Medicaid | MI |
Other providers in Gladstone, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 17, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.