Healthcare Provider Details

I. General information

NPI: 1225052012
Provider Name (Legal Business Name): KEVIN JAMES DONATHAN DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17533 FORT ST
RIVERVIEW MI
48193-6630
US

IV. Provider business mailing address

17533 FORT ST
RIVERVIEW MI
48193-6630
US

V. Phone/Fax

Practice location:
  • Phone: 734-283-3200
  • Fax: 734-283-5541
Mailing address:
  • Phone: 734-283-3200
  • Fax: 734-283-5541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number2301007586
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: