Provider Demographics
NPI:1386641884
Name:PERRAULT, KIRBY KENNETH (DC)
Entity Type:Individual
Prefix:
First Name:KIRBY
Middle Name:KENNETH
Last Name:PERRAULT
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 1:2199 JOLLY RD
Mailing Address - Street 2:SUITE # 140
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-3968
Mailing Address - Country:US
Mailing Address - Phone:517-381-1880
Mailing Address - Fax:517-381-1990
Practice Address - Street 1:2199 JOLLY RD
Practice Address - Street 2:SUITE # 140
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-3968
Practice Address - Country:US
Practice Address - Phone:517-381-1880
Practice Address - Fax:517-381-1990
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2009-07-08
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
MI2301007563111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950C350 750OtherBCBS PIN
MI950C350 750OtherBCBS PIN
MIU71734Medicare UPIN