Provider Demographics
NPI:1275789539
Name:DE BOARD CHIROPRACTIC P C
Entity Type:Organization
Organization Name:DE BOARD CHIROPRACTIC P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:D
Authorized Official - Last Name:DEBOARD
Authorized Official - Suffix:
Authorized Official - Credentials:D C
Authorized Official - Phone:269-651-9448
Mailing Address - Street 1:204 E WEST ST
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091-1444
Mailing Address - Country:US
Mailing Address - Phone:269-651-9448
Mailing Address - Fax:269-659-3228
Practice Address - Street 1:204 E WEST ST
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-1444
Practice Address - Country:US
Practice Address - Phone:269-651-9448
Practice Address - Fax:269-659-3228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007577111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950G510810OtherBCBS ID
MI0M66050OtherMEDICARE ID
MI950G510810OtherBCN ID
MI44-30215OtherPHP
MI950G510810OtherBCN ID