Provider Demographics
NPI:1003810060
Name:ANDERSON, TRENT MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:TRENT
Middle Name:MICHAEL
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5550
Mailing Address - Country:US
Mailing Address - Phone:812-323-0700
Mailing Address - Fax:812-323-0702
Practice Address - Street 1:4211 E 3RD ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-5550
Practice Address - Country:US
Practice Address - Phone:812-323-0700
Practice Address - Fax:812-323-0702
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001705A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU64956Medicare UPIN
IN214780AMedicare ID - Type Unspecified