Provider Demographics
NPI:1407814502
Name:DEBOARD, TIMOTHY DARYLL (DC)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:DARYLL
Last Name:DEBOARD
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 1:204 E WEST ST
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091-1444
Mailing Address - Country:US
Mailing Address - Phone:269-651-9448
Mailing Address - Fax:269-659-3228
Practice Address - Street 1:204 E WEST ST
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-1444
Practice Address - Country:US
Practice Address - Phone:269-651-9448
Practice Address - Fax:269-659-3228
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007577111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950G510810OtherBCN ID
MI950G510810OtherBCBS ID
MI44-30215OtherPHP
MIU76373Medicare UPIN
MI950G510810OtherBCBS ID