Provider Demographics
NPI:1700969284
Name:WILLEMIN, DOUGLAS L (DC)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:L
Last Name:WILLEMIN
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:PO BOX 338
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:MI
Mailing Address - Zip Code:48884-0338
Mailing Address - Country:US
Mailing Address - Phone:989-291-3202
Mailing Address - Fax:989-291-3203
Practice Address - Street 1:500 S MAIN ST
Practice Address - Street 2:STE 2
Practice Address - City:SHERIDAN
Practice Address - State:MI
Practice Address - Zip Code:48884-9775
Practice Address - Country:US
Practice Address - Phone:989-291-3202
Practice Address - Fax:989-291-3203
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004754111N00000X
GACHIR002580111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2123215Medicaid
MIT33288Medicare UPIN
MIOE95008Medicare ID - Type Unspecified