Provider Demographics
NPI:1053489542
Name:KOTCHOUNIAN, ANTOINETTE (DC)
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:KOTCHOUNIAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6229 WILLITS RD
Mailing Address - Street 2:
Mailing Address - City:FOSTORIA
Mailing Address - State:MI
Mailing Address - Zip Code:48435-9420
Mailing Address - Country:US
Mailing Address - Phone:810-793-7376
Mailing Address - Fax:810-793-7647
Practice Address - Street 1:604 S MAIN ST
Practice Address - Street 2:#170
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-2463
Practice Address - Country:US
Practice Address - Phone:810-793-7376
Practice Address - Fax:810-793-7647
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAK005901111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3186265Medicaid
MI0D41027OtherBCBSM PIN
MI0D45144Medicare ID - Type Unspecified
MI3186265Medicaid