Provider Demographics
NPI:1073978318
Name:DEER CREEK MEDICAL GROUP
Entity Type:Organization
Organization Name:DEER CREEK MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRFESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BASTKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:954-531-0420
Mailing Address - Street 1:PO BOX 4102
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33442-4102
Mailing Address - Country:US
Mailing Address - Phone:954-531-0420
Mailing Address - Fax:954-531-0268
Practice Address - Street 1:3401 DEER CREEK COUNTRY CLUB BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33442-8427
Practice Address - Country:US
Practice Address - Phone:954-531-0420
Practice Address - Fax:954-531-0268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7166111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty