Provider Demographics
NPI:1881688562
Name:BLOSSOM, DANIEL ERWIN (DC)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:ERWIN
Last Name:BLOSSOM
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 1:811 W HURON AVE
Mailing Address - Street 2:
Mailing Address - City:VASSAR
Mailing Address - State:MI
Mailing Address - Zip Code:48768-1128
Mailing Address - Country:US
Mailing Address - Phone:989-823-7076
Mailing Address - Fax:
Practice Address - Street 1:811 W HURON AVE
Practice Address - Street 2:
Practice Address - City:VASSAR
Practice Address - State:MI
Practice Address - Zip Code:48768-1128
Practice Address - Country:US
Practice Address - Phone:989-823-7076
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004810111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G95011Medicare ID - Type Unspecified
MI36473Medicare UPIN