Provider Demographics
NPI:1619035474
Name:MAYNARD, ALAN EMERY (DC)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:EMERY
Last Name:MAYNARD
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 1:2934 NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2418
Mailing Address - Country:US
Mailing Address - Phone:269-983-2292
Mailing Address - Fax:269-983-6155
Practice Address - Street 1:2934 NILES AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2418
Practice Address - Country:US
Practice Address - Phone:269-983-2292
Practice Address - Fax:269-983-6155
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006933111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI382877133OtherTAX ID
MIOA150910OtherBCBSMI
MI382877133OtherTAX ID