Provider Demographics
NPI:1780368340
Name:100 CHIRO DEHAVEN PLLC
Entity type:Organization
Organization Name:100 CHIRO DEHAVEN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DORIAN
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:DEHAVEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:616-826-0275
Mailing Address - Street 1:15056 BIGNELL DR
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-9139
Mailing Address - Country:US
Mailing Address - Phone:616-826-0275
Mailing Address - Fax:
Practice Address - Street 1:446 RINEHART RD
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-5242
Practice Address - Country:US
Practice Address - Phone:616-826-0275
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-14
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty