Provider Demographics
NPI:1558639559
Name:ANDERSEN, AUSTIN LEE (DC)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:LEE
Last Name:ANDERSEN
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 1:101 E FERRY ST
Mailing Address - Street 2:
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103-1160
Mailing Address - Country:US
Mailing Address - Phone:269-473-3007
Mailing Address - Fax:269-473-3610
Practice Address - Street 1:101 E FERRY ST
Practice Address - Street 2:
Practice Address - City:BERRIEN SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49103-1160
Practice Address - Country:US
Practice Address - Phone:269-473-3007
Practice Address - Fax:269-473-3610
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009890111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor