Provider Demographics
NPI:1255460994
Name:BOURNE, ANDREW J (DC)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:J
Last Name:BOURNE
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 1:9304 NEW LAGRANGE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40242-3671
Mailing Address - Country:US
Mailing Address - Phone:502-426-4511
Mailing Address - Fax:502-426-0529
Practice Address - Street 1:9304 NEW LAGRANGE RD STE 100
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40242-3671
Practice Address - Country:US
Practice Address - Phone:502-426-4511
Practice Address - Fax:502-426-0529
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4617111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000211276Other12 DIGIT ANTHEM PROVIDER
KYTB61OtherANTHEM 4 DIGIT PROVIDER
KYP00077606OtherRR MEDICARE #
KY000000211276Other12 DIGIT ANTHEM PROVIDER
KY6103001Medicare ID - Type UnspecifiedMEDICARE PROVIDER #