Provider Demographics
NPI:1750378659
Name:BORN, BRYAN (DC)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:
Last Name:BORN
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 1:15831 W 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-3011
Mailing Address - Country:US
Mailing Address - Phone:248-559-6763
Mailing Address - Fax:
Practice Address - Street 1:15831 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-3011
Practice Address - Country:US
Practice Address - Phone:248-559-6763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-05
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005852111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950F353420OtherBCBS
MIU25919Medicare UPIN
MI950F353420OtherBCBS