Provider Demographics
NPI:1518971647
Name:BAKER, BRUCE BOARDMAN (DC)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:BOARDMAN
Last Name:BAKER
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 1:3388 I 75 BUSINESS SPUR
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-3605
Mailing Address - Country:US
Mailing Address - Phone:906-635-0196
Mailing Address - Fax:906-635-8295
Practice Address - Street 1:3388 I 75 BUSINESS SPUR
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-3605
Practice Address - Country:US
Practice Address - Phone:906-635-0196
Practice Address - Fax:906-635-8295
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBB005180111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1722510Medicaid
MI0A75000Medicare ID - Type UnspecifiedMEDICARE ID #
MI1722510Medicaid