Provider Demographics
NPI:1003197443
Name:ADVANCED CHIROPRACTIC OF BERRIEN SPRINGS
Entity Type:Organization
Organization Name:ADVANCED CHIROPRACTIC OF BERRIEN SPRINGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:STOWE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:269-471-5433
Mailing Address - Street 1:200 N CASS ST
Mailing Address - Street 2:
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103-1161
Mailing Address - Country:US
Mailing Address - Phone:269-471-5433
Mailing Address - Fax:269-471-1209
Practice Address - Street 1:200 N CASS ST
Practice Address - Street 2:
Practice Address - City:BERRIEN SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49103-1161
Practice Address - Country:US
Practice Address - Phone:269-471-5433
Practice Address - Fax:269-471-1209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-30
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004493111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI95-0A112100OtherBCBS
MI95-0A112100OtherBCBS