Provider Demographics
NPI:1174706758
Name:BEND CHIROPRACTIC CLINIC PC
Entity type:Organization
Organization Name:BEND CHIROPRACTIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:BEND
Authorized Official - Suffix:SR
Authorized Official - Credentials:DC
Authorized Official - Phone:586-725-1111
Mailing Address - Street 1:37339 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:NEW BALTIMORE
Mailing Address - State:MI
Mailing Address - Zip Code:48047-1664
Mailing Address - Country:US
Mailing Address - Phone:586-725-1111
Mailing Address - Fax:586-725-8041
Practice Address - Street 1:37339 GREEN ST
Practice Address - Street 2:
Practice Address - City:NEW BALTIMORE
Practice Address - State:MI
Practice Address - Zip Code:48047-1664
Practice Address - Country:US
Practice Address - Phone:586-725-1111
Practice Address - Fax:586-725-8041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1404329Medicaid
MI6258800001Medicare NSC
MI0E05068Medicare PIN