Provider Demographics
NPI:1750450078
Name:POULIN, MIKE M (DC)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:M
Last Name:POULIN
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 1:2465 CENTREVILLE RD STE J18
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-3026
Mailing Address - Country:US
Mailing Address - Phone:703-561-0600
Mailing Address - Fax:703-561-0601
Practice Address - Street 1:2465 CENTREVILLE RD STE J18
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20171-3026
Practice Address - Country:US
Practice Address - Phone:703-561-0600
Practice Address - Fax:703-561-0601
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104001170111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA211741OtherANTHEM
VAF610-0001OtherCAREFIRST BLUE CROSS
VA211741OtherANTHEM