Provider Demographics
NPI:1083836084
Name:BASTIEN, THOMAS R (DC)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:R
Last Name:BASTIEN
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 1:2135 PLAINFIELD AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-4203
Mailing Address - Country:US
Mailing Address - Phone:616-363-2822
Mailing Address - Fax:616-363-0905
Practice Address - Street 1:2135 PLAINFIELD AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-4203
Practice Address - Country:US
Practice Address - Phone:616-363-2822
Practice Address - Fax:616-363-0905
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006501111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3263103Medicaid
MI0D15037Medicare ID - Type Unspecified