Provider Demographics
NPI:1457312951
Name:RAMBOER, GREGORY DALE (DC)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:DALE
Last Name:RAMBOER
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 1:5896 DIXIE HWY
Mailing Address - Street 2:STE A
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346
Mailing Address - Country:US
Mailing Address - Phone:248-623-6107
Mailing Address - Fax:248-623-6443
Practice Address - Street 1:5896 DIXIE HWY
Practice Address - Street 2:STE A
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346
Practice Address - Country:US
Practice Address - Phone:248-623-6107
Practice Address - Fax:248-623-6443
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-01
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIGR008055111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950F355370OtherBLUE CROSS BLUE SHIELD
MI950F355370OtherBLUE CROSS BLUE SHIELD
N30330002Medicare ID - Type Unspecified