Provider Demographics
NPI:1164525747
Name:CHILDS, ETHAN H (DC)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:H
Last Name:CHILDS
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 1:229 N BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:GRAND LEDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48837
Mailing Address - Country:US
Mailing Address - Phone:517-627-7070
Mailing Address - Fax:517-627-0976
Practice Address - Street 1:229 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:GRAND LEDGE
Practice Address - State:MI
Practice Address - Zip Code:48837
Practice Address - Country:US
Practice Address - Phone:517-627-7070
Practice Address - Fax:517-627-0976
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008476111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI9508350410OtherBCBS
MI1009988OtherMCLAREN
MI4570468Medicaid
U87870Medicare UPIN
MI4570468Medicaid