1487608162 NPI number — BOSMAN CHIROPRACTIC LIFE CENTER, P.C.

Table of content: (NPI 1487608162)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487608162 NPI number — BOSMAN CHIROPRACTIC LIFE CENTER, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOSMAN CHIROPRACTIC LIFE CENTER, 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:
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:
1487608162
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
709 S OPDYKE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUBURN HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48326-3436
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-253-1700
Provider Business Mailing Address Fax Number:
248-253-1707

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
709 S OPDYKE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUBURN HILLS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48326-3436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-253-1700
Provider Business Practice Location Address Fax Number:
248-253-1707
Provider Enumeration Date:
05/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOSMAN
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
JOSEPH
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-253-1700

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2301007418 , 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: 0F34187 . This is a "BLUE CROSS BLUE SHIELD PROVIDER NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0F35426 . This is a "BCBS PROVIDER ID NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4375884 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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