1245367366 NPI number — HUDSON CHIROPRACTIC PC

Table of content: (NPI 1245367366)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245367366 NPI number — HUDSON CHIROPRACTIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HUDSON CHIROPRACTIC PC
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:
1245367366
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 31
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUDSON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49247-0031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-448-8515
Provider Business Mailing Address Fax Number:
517-448-3044

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
794 N MAPLE GROVE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUDSON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49247-1148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-448-8515
Provider Business Practice Location Address Fax Number:
517-448-3044
Provider Enumeration Date:
02/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LAUT
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
RAY
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
517-448-8515

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2301004913 , 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: SL004913 . This is a "PRIVATE INS. PROVIDER ID#" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4343700 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 950D650020 . This is a "BCBSM PROVIDER ID#" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 36362049700 . This is a "WORKERS COMP" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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