Provider Demographics
NPI:1134856305
Name:PREVOST, JOHN ANTHONY III (DC)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ANTHONY
Last Name:PREVOST
Suffix:III
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 1:2462 GOLDEN SHORE DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-1051
Mailing Address - Country:US
Mailing Address - Phone:810-247-2551
Mailing Address - Fax:
Practice Address - Street 1:1016 N SAGINAW ST
Practice Address - Street 2:
Practice Address - City:HOLLY
Practice Address - State:MI
Practice Address - Zip Code:48442-1379
Practice Address - Country:US
Practice Address - Phone:248-328-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-06
Last Update Date:2022-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301401273111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor