=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376887638
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALMOND LEAF CHIROPRACTIC, PLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2012
-----------------------------------------------------
Last Update Date | 01/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6411 BELLA VISTA DR NE STE #2
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49341-7869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-874-7255
-----------------------------------------------------
Fax | 616-874-7196
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6411 BELLA VISTA DR NE STE #2
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49341-7869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-874-7255
-----------------------------------------------------
Fax | 616-874-7196
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MATT R. DEVREUGD
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 616-874-7255
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------