Provider Demographics
NPI:1811927171
Name:GLEASON, DANIEL CLARENCE (DC)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:CLARENCE
Last Name:GLEASON
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 1:19084 N FRUITPORT RD
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-1163
Mailing Address - Country:US
Mailing Address - Phone:616-846-5410
Mailing Address - Fax:616-846-3585
Practice Address - Street 1:19084 N FRUITPORT RD
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-1163
Practice Address - Country:US
Practice Address - Phone:616-846-5410
Practice Address - Fax:616-846-3585
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301002923111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP37960001Medicare PIN