Provider Demographics
NPI:1306061296
Name:BAY DE NOC CHIROPRACTIC CENTER, P.C.
Entity type:Organization
Organization Name:BAY DE NOC CHIROPRACTIC CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BOUDREAU
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:906-428-9640
Mailing Address - Street 1:116 N 9TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:GLADSTONE
Mailing Address - State:MI
Mailing Address - Zip Code:49837-1660
Mailing Address - Country:US
Mailing Address - Phone:906-428-9640
Mailing Address - Fax:906-428-9641
Practice Address - Street 1:116 N 9TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:GLADSTONE
Practice Address - State:MI
Practice Address - Zip Code:49837-1660
Practice Address - Country:US
Practice Address - Phone:906-428-9640
Practice Address - Fax:906-428-9641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008810111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIV02443Medicare UPIN
MI0P03420Medicare ID - Type Unspecified