Provider Demographics
NPI:1598712267
Name:DEANDA CHIROPRACTIC CLINIC LLC
Entity Type:Organization
Organization Name:DEANDA CHIROPRACTIC CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:KERN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:810-765-9700
Mailing Address - Street 1:2887 KRAFFT RD
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060
Mailing Address - Country:US
Mailing Address - Phone:810-984-1994
Mailing Address - Fax:810-984-3266
Practice Address - Street 1:2887 KRAFFT RD
Practice Address - Street 2:SUITE 1400
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060
Practice Address - Country:US
Practice Address - Phone:810-984-1994
Practice Address - Fax:810-984-3266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005582111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950G410520OtherBCBS
MI4776847Medicaid
MI0N62360Medicare ID - Type Unspecified
MI950G410520OtherBCBS