Provider Demographics
NPI:1679516223
Name:BOUDREAU, KEVIN LAWRENCE (DC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:LAWRENCE
Last Name:BOUDREAU
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 1:116 N 9TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:GLADSTONE
Mailing Address - State:MI
Mailing Address - Zip Code:49837-1645
Mailing Address - Country:US
Mailing Address - Phone:906-428-9640
Mailing Address - Fax:906-428-9641
Practice Address - Street 1:116 N 9TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:GLADSTONE
Practice Address - State:MI
Practice Address - Zip Code:49837-1645
Practice Address - Country:US
Practice Address - Phone:906-428-9640
Practice Address - Fax:906-428-9641
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008810111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P032420Medicare ID - Type Unspecified
MIV02443Medicare UPIN