Provider Demographics
NPI:1154773554
Name:TERWILLIGER, BROOKE (DC)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:TERWILLIGER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 S WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:OTISVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48463-9492
Mailing Address - Country:US
Mailing Address - Phone:810-625-0128
Mailing Address - Fax:
Practice Address - Street 1:5363 N STATE RD
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-8595
Practice Address - Country:US
Practice Address - Phone:810-652-6434
Practice Address - Fax:810-652-6435
Is Sole Proprietor?:No
Enumeration Date:2016-07-08
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010458111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI10272002Medicare UPIN
MIMI10272Medicare PIN