Provider Demographics
NPI:1598749830
Name:JIMINES, RICHARD X (DC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:JIMINES
Suffix:X
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 1:15111 E 13 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48088-3396
Mailing Address - Country:US
Mailing Address - Phone:586-415-8068
Mailing Address - Fax:586-415-8145
Practice Address - Street 1:15111 E 13 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-3396
Practice Address - Country:US
Practice Address - Phone:586-415-8068
Practice Address - Fax:586-415-8145
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301400093111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950E051410OtherBLUECROSS BLUESHIELD OF M
MI0E05141Medicare ID - Type Unspecified