Provider Demographics
NPI:1508831108
Name:FOWLER, THOMAS J (DC, DACRB)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:FOWLER
Suffix:
Gender:M
Credentials:DC, DACRB
Other - Prefix:DR
Other - First Name:THOMAS
Other - Middle Name:
Other - Last Name:FOWLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC, DARCB
Mailing Address - Street 1:335 N 120TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-2118
Mailing Address - Country:US
Mailing Address - Phone:616-392-3363
Mailing Address - Fax:616-392-9030
Practice Address - Street 1:335 N 120TH AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-2118
Practice Address - Country:US
Practice Address - Phone:616-392-3363
Practice Address - Fax:616-392-9030
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005434111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G05009Medicare ID - Type UnspecifiedTF MEDICARE
MI950G050090OtherTF BCBSMI
MIT33503Medicare UPIN
MI2301005434OtherTF STATE
MI0P23670001Medicare ID - Type UnspecifiedTF MEDICARE
MI141816466Medicaid