1003197443 NPI number — ADVANCED CHIROPRACTIC OF BERRIEN SPRINGS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003197443 NPI number — ADVANCED CHIROPRACTIC OF BERRIEN SPRINGS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED CHIROPRACTIC OF BERRIEN SPRINGS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003197443
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 N CASS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BERRIEN SPRINGS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49103-1161
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-471-5433
Provider Business Mailing Address Fax Number:
269-471-1209

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 N CASS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERRIEN SPRINGS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49103-1161
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-471-5433
Provider Business Practice Location Address Fax Number:
269-471-1209
Provider Enumeration Date:
08/30/2011

Additional Information

Authorized Official

Authorized Official Last Name:
STOWE
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
269-471-5433

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2301004493 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 95-0A112100 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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