1144234451 NPI number — VAN BUREN CHIROPRACTIC CLINIC, P.C.

Table of content: (NPI 1144234451)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144234451 NPI number — VAN BUREN CHIROPRACTIC CLINIC, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VAN BUREN CHIROPRACTIC CLINIC, P.C.
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:
1144234451
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
309 S KALAMAZOO ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAW PAW
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49079-1527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-657-7005
Provider Business Mailing Address Fax Number:
269-657-7007

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
309 S KALAMAZOO ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAW PAW
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49079-1527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-657-7005
Provider Business Practice Location Address Fax Number:
269-657-7007
Provider Enumeration Date:
07/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TATTERSALL
Authorized Official First Name:
RAYMOND
Authorized Official Middle Name:
CHARLES
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
269-657-7005

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2301004320 , 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: 16123 . This is a "MCARE PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 44-30051 . This is a "IBA/PHP NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 2301004320 . This is a "LICENSE NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P67311 . This is a "BLUE CARE NETWORK PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1935037 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: RT004320 . This is a "BCBS PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 950H05002 . This is a "BCBS MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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