=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659591709
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES FRED DECKER DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2007
-----------------------------------------------------
Last Update Date | 05/31/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1324 S PARK ST STE 3
-----------------------------------------------------
City | KALAMAZOO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49001-2735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-381-2800
-----------------------------------------------------
Fax | 269-381-2808
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 913 N DARTMOUTH ST
-----------------------------------------------------
City | KALAMAZOO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49006-3304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-873-7815
-----------------------------------------------------
Fax | 269-381-2808
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NS0005X
-----------------------------------------------------
Taxonomy Name | Sports Physician Chiropractor
-----------------------------------------------------
License Number | 2301009520
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------