Healthcare Provider Details

I. General information

NPI: 1609322486
Provider Name (Legal Business Name): BIRCH RUN CHIROPRACTIC CLINIC PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 01/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7890 MAIN
BIRCH RUN MI
48415
US

IV. Provider business mailing address

PO BOX 399
BIRCH RUN MI
48415-0399
US

V. Phone/Fax

Practice location:
  • Phone: 989-624-6266
  • Fax: 989-624-4407
Mailing address:
  • Phone: 989-624-6266
  • Fax: 989-624-4407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301005216
License Number StateMI

VIII. Authorized Official

Name: DR. KENNETH ROBERT TILLER
Title or Position: PRESIDENT
Credential: D.C.
Phone: 989-624-6266