MEDICARE: DR. DOUGLAS GENE MCKENZIE D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	2301008451	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DM008451	OTHER	MI	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1902928724
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOUGLAS GENE MCKENZIE D.C.

Provider Business Mailing Address
First Line	:	3138 BROADMOOR AVE SE
Second Line	:
City	:	KENTWOOD
State	:	MI
Zip	:	49512-1845
Country	:	US
Telephone Number	:	616-241-4040
Fax Number	:	616-475-6953

Provider Business Practice Location Address
First Line	:	3138 BROADMOOR AVE SE
Second Line	:
City	:	KENTWOOD
State	:	MI
Zip	:	49512-1845
Country	:	US
Telephone Number	:	616-241-4040
Fax Number	:	616-475-6953

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	07/08/2007

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