Provider Demographics
NPI:1922152792
Name:DANIEL JOSEPH BOURQUE
Entity Type:Organization
Organization Name:DANIEL JOSEPH BOURQUE
Other - Org Name:DANIELS CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BOURQUE
Authorized Official - Suffix:
Authorized Official - Credentials:DC,
Authorized Official - Phone:541-389-1191
Mailing Address - Street 1:2207 NW AWBREY RD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-1218
Mailing Address - Country:US
Mailing Address - Phone:541-389-1191
Mailing Address - Fax:541-389-1972
Practice Address - Street 1:2207 NW AWBREY RD
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-1218
Practice Address - Country:US
Practice Address - Phone:541-389-1191
Practice Address - Fax:541-389-1972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3196111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR108119Medicare PIN