Provider Demographics
NPI:1376713347
Name:WARNER DE LEEUW IV, PC
Entity Type:Organization
Organization Name:WARNER DE LEEUW IV, PC
Other - Org Name:AMERICAN CHIROPRACTIC CENTER PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WARNER
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LEEUW IV
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:616-243-1444
Mailing Address - Street 1:738 32ND ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-2329
Mailing Address - Country:US
Mailing Address - Phone:616-243-1444
Mailing Address - Fax:616-243-2434
Practice Address - Street 1:738 32ND ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-2329
Practice Address - Country:US
Practice Address - Phone:616-243-1444
Practice Address - Fax:616-243-2434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009355111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0P57110OtherMEDICARE PTAN