Provider Demographics
NPI:1144234451
Name:VAN BUREN CHIROPRACTIC CLINIC, P.C.
Entity Type:Organization
Organization Name:VAN BUREN CHIROPRACTIC CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:TATTERSALL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:269-657-7005
Mailing Address - Street 1:309 S KALAMAZOO ST
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-1527
Mailing Address - Country:US
Mailing Address - Phone:269-657-7005
Mailing Address - Fax:269-657-7007
Practice Address - Street 1:309 S KALAMAZOO ST
Practice Address - Street 2:
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1527
Practice Address - Country:US
Practice Address - Phone:269-657-7005
Practice Address - Fax:269-657-7007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004320111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI16123OtherMCARE PIN
MI44-30051OtherIBA/PHP NUMBER
MI2301004320OtherLICENSE NUMBER
MIP67311OtherBLUE CARE NETWORK PIN
MI1935037Medicaid
MIRT004320OtherBCBS PIN
MI950H05002OtherBCBS MICHIGAN
MIU11237Medicare UPIN
MI16123OtherMCARE PIN