Provider Demographics
NPI:1679840292
Name:SPORTS & FAMILY CHIROPRACTIC CENTER, PLLC
Entity type:Organization
Organization Name:SPORTS & FAMILY CHIROPRACTIC CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:GLEASON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:603-890-3486
Mailing Address - Street 1:31 LOWELL RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:WINDHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03087-1857
Mailing Address - Country:US
Mailing Address - Phone:603-890-3486
Mailing Address - Fax:603-890-6234
Practice Address - Street 1:31 LOWELL RD
Practice Address - Street 2:SUITE 5
Practice Address - City:WINDHAM
Practice Address - State:NH
Practice Address - Zip Code:03087-1857
Practice Address - Country:US
Practice Address - Phone:603-890-3486
Practice Address - Fax:603-890-6234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH074-0491111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH1548348568Medicare UPIN