Provider Demographics
NPI:1093801201
Name:TILLER, KENNETH ROBERT (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ROBERT
Last Name:TILLER
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:PO BOX 399
Mailing Address - Street 2:7890 MAIN
Mailing Address - City:BIRCH RUN
Mailing Address - State:MI
Mailing Address - Zip Code:48415
Mailing Address - Country:US
Mailing Address - Phone:989-624-6266
Mailing Address - Fax:989-624-4407
Practice Address - Street 1:7890 MAIN
Practice Address - Street 2:
Practice Address - City:BIRCH RUN
Practice Address - State:MI
Practice Address - Zip Code:48415
Practice Address - Country:US
Practice Address - Phone:989-624-6266
Practice Address - Fax:989-624-4407
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005216111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2928135Medicaid
MI391945651OtherAETNA
MI950G35246OtherBCBS
0G35246Medicare ID - Type Unspecified
MI33416Medicare UPIN