Provider Demographics
NPI:1093764292
Name:DEHAVEN, ANDREW A (DC)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:A
Last Name:DEHAVEN
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 1:7652 RED ARROW HWY
Mailing Address - Street 2:PO BOX 245
Mailing Address - City:WATERVLIET
Mailing Address - State:MI
Mailing Address - Zip Code:49098-9396
Mailing Address - Country:US
Mailing Address - Phone:269-463-5700
Mailing Address - Fax:269-463-3645
Practice Address - Street 1:7652 RED ARROW HWY
Practice Address - Street 2:
Practice Address - City:WATERVLIET
Practice Address - State:MI
Practice Address - Zip Code:49098-9396
Practice Address - Country:US
Practice Address - Phone:269-463-5700
Practice Address - Fax:269-463-3645
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007097111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950A15056OtherBLUE CROSS BLUE SHIELD MI
MI0M02910Medicare ID - Type Unspecified
MI950A15056OtherBLUE CROSS BLUE SHIELD MI