1811196272 NPI number — NEW BOSTON CHIROPRACTIC LIFE CENTER, CORPORATION

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 1811196272 NPI number — NEW BOSTON CHIROPRACTIC LIFE CENTER, CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW BOSTON CHIROPRACTIC LIFE CENTER, CORPORATION
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:
1811196272
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
405 E CHICAGO BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TECUMSEH
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49286-1513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-423-2639
Provider Business Mailing Address Fax Number:
517-423-0639

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 E CHICAGO BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TECUMSEH
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49286-1513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-423-2639
Provider Business Practice Location Address Fax Number:
517-423-0639
Provider Enumeration Date:
07/16/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MCFARLAND
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
KIM
Authorized Official Title or Position:
DOCTOR OF CHIROPRACTIC/ PRESIDENT
Authorized Official Telephone Number:
517-423-2639

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2301008358 , 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: 95-0D60102-0 . This is a "BLUE CROSS GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P11040001 . This is a "MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".