Provider Demographics
NPI:1528410842
Name:MICHAEL DECKER, DO, INC
Entity Type:Organization
Organization Name:MICHAEL DECKER, DO, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DECKER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:816-896-1355
Mailing Address - Street 1:565 PIER AVE
Mailing Address - Street 2:#1352
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-8200
Mailing Address - Country:US
Mailing Address - Phone:816-896-1355
Mailing Address - Fax:
Practice Address - Street 1:565 PIER AVE
Practice Address - Street 2:#1352
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-8200
Practice Address - Country:US
Practice Address - Phone:816-896-1355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A13087314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility