1336269190 NPI number — DEFLORES CHIROPRACTIC CLINICS PC

Table of content: (NPI 1336269190)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336269190 NPI number — DEFLORES CHIROPRACTIC CLINICS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEFLORES CHIROPRACTIC CLINICS 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:
6
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:
1336269190
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
12/28/2007
NPI Reactivation Date:
01/30/2008

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5065 MILLER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLINT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48507-1037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-732-6780
Provider Business Mailing Address Fax Number:
810-733-7246

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5065 MILLER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLINT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48507-1037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-732-6780
Provider Business Practice Location Address Fax Number:
810-733-7246
Provider Enumeration Date:
03/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BLOSSOM
Authorized Official First Name:
AARON
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
810-732-6780

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2301002227 , 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: 0005935508 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 135332500 . This is a "U.S. DEPARTMENT OF LABOR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 350026642 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 950B551410 . This is a "BLUECROSSBLUESHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1002107 . This is a "MCLAREN HEALTHCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 01003624 . This is a "HEALTH PLUS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: CL4205 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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