Provider Demographics
NPI:1205017662
Name:BRONKHORST, MICHELLE LYNNE (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:LYNNE
Last Name:BRONKHORST
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 BAKER ST
Mailing Address - Street 2:327
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-4428
Mailing Address - Country:US
Mailing Address - Phone:714-751-5170
Mailing Address - Fax:
Practice Address - Street 1:660 BAKER ST
Practice Address - Street 2:327
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4428
Practice Address - Country:US
Practice Address - Phone:714-751-5170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21908111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC21908Medicare PIN