Provider Demographics
NPI:1366706004
Name:MAYNARD CHIROPRACTIC PLLC
Entity type:Organization
Organization Name:MAYNARD CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:EMERY
Authorized Official - Last Name:MAYNARD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:269-983-2292
Mailing Address - Street 1:2934 NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2418
Mailing Address - Country:US
Mailing Address - Phone:269-983-2292
Mailing Address - Fax:269-983-6155
Practice Address - Street 1:2934 NILES AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2418
Practice Address - Country:US
Practice Address - Phone:269-983-2292
Practice Address - Fax:269-983-6155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006933111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0A10068OtherBCBSMI
MI1619035474OtherPROVIDER NPI
MIOA15091OtherMEDICARE
MI1619035474OtherPROVIDER NPI