Provider Demographics
NPI:1023067618
Name:GRONDIN, TIMOTHY (CHIROPRACTOR)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:GRONDIN
Suffix:
Gender:M
Credentials:CHIROPRACTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1831 PINE GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3120
Mailing Address - Country:US
Mailing Address - Phone:810-984-3344
Mailing Address - Fax:
Practice Address - Street 1:1831 PINE GROVE AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3120
Practice Address - Country:US
Practice Address - Phone:810-984-3344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006814111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950G45010OtherBC/BS PROVIDER NUMBER
MI0G45010Medicare ID - Type Unspecified
MI950G45010OtherBC/BS PROVIDER NUMBER