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General NPI Number Information
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NPI Number | 1306061296
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Entity Type | Organization
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Legal Business Name | BAY DE NOC CHIROPRACTIC CENTER, P.C.
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Dates
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Enumeration Date | 04/16/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 116 N 9TH ST SUITE A
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City | GLADSTONE
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State | MI
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Zip | 49837-1660
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Country | US
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Telephone | 906-428-9640
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Fax | 906-428-9641
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Provider Business Mailing Address
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Address Line | 116 N 9TH ST SUITE A
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City | GLADSTONE
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State | MI
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Zip | 49837-1660
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Country | US
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Telephone | 906-428-9640
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Fax | 906-428-9641
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Authorized Official
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Title or Position | OWNER
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Name | DR. KEVIN L BOUDREAU
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Credential | D.C.
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Telephone | 906-428-9640
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 2301008810
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License Number State | MI
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