Provider Demographics
NPI:1366748923
Name:MASTERS, RONALD MAXWELL (DC)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:MAXWELL
Last Name:MASTERS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 PHOENIX ST STE 9
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-8658
Mailing Address - Country:US
Mailing Address - Phone:269-639-2545
Mailing Address - Fax:269-639-2137
Practice Address - Street 1:1675 PHOENIX ST STE 9
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-8658
Practice Address - Country:US
Practice Address - Phone:269-639-2545
Practice Address - Fax:269-639-2137
Is Sole Proprietor?:No
Enumeration Date:2011-01-31
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009746111N00000X
IL038012165111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0044472879Medicaid
MI950A310570OtherBCBSM
MIG06732OtherBCN
MIG06732OtherBCN