MEDICARE: DR. KEVIN LAWRENCE BOUDREAU D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	2301008810	MI

General Provider Information

NPI Number	:	1679516223
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEVIN LAWRENCE BOUDREAU D.C.

Provider Business Mailing Address
First Line	:	116 N 9TH ST
Second Line	:	SUITE A
City	:	GLADSTONE
State	:	MI
Zip	:	49837-1645
Country	:	US
Telephone Number	:	906-428-9640
Fax Number	:	906-428-9641

Provider Business Practice Location Address
First Line	:	116 N 9TH ST
Second Line	:	SUITE A
City	:	GLADSTONE
State	:	MI
Zip	:	49837-1645
Country	:	US
Telephone Number	:	906-428-9640
Fax Number	:	906-428-9641

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2006
Last Update Date	:	07/08/2007

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