Healthcare Provider Details

I. General information

NPI: 1083836084
Provider Name (Legal Business Name): THOMAS R BASTIEN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2135 PLAINFIELD AVE NE
GRAND RAPIDS MI
49505-4203
US

IV. Provider business mailing address

2135 PLAINFIELD AVE NE
GRAND RAPIDS MI
49505-4203
US

V. Phone/Fax

Practice location:
  • Phone: 616-363-2822
  • Fax: 616-363-0905
Mailing address:
  • Phone: 616-363-2822
  • Fax: 616-363-0905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301006501
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: