Provider Demographics
NPI:1801841846
Name:HOMER, KEVIN JEREMY (DC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:JEREMY
Last Name:HOMER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:KEVIN
Other - Middle Name:J
Other - Last Name:HOMER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:7180 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-5109
Mailing Address - Country:US
Mailing Address - Phone:248-625-7690
Mailing Address - Fax:248-625-7140
Practice Address - Street 1:7180 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-5109
Practice Address - Country:US
Practice Address - Phone:248-625-7690
Practice Address - Fax:248-625-7140
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008892111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4905935Medicaid
V02176Medicare UPIN
MIN83750004Medicare PIN