Healthcare Provider Details

I. General information

NPI: 1063705838
Provider Name (Legal Business Name): JEREMY R BAKER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2011
Last Update Date: 05/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 N MAIN ST
STURGIS KY
42459-1630
US

IV. Provider business mailing address

412 N MAIN ST PO BOX 124
STURGIS KY
42459-1630
US

V. Phone/Fax

Practice location:
  • Phone: 270-333-4641
  • Fax: 270-333-4641
Mailing address:
  • Phone: 270-333-4641
  • Fax: 270-333-4641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5292
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: