Provider Demographics
NPI:1487702254
Name:FAIRBANKS, DAVID LEE (DC)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:LEE
Last Name:FAIRBANKS
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 1:510 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:MI
Mailing Address - Zip Code:49837-1613
Mailing Address - Country:US
Mailing Address - Phone:906-428-1679
Mailing Address - Fax:906-428-4643
Practice Address - Street 1:510 S 9TH ST
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:MI
Practice Address - Zip Code:49837-1613
Practice Address - Country:US
Practice Address - Phone:906-428-1679
Practice Address - Fax:906-428-4643
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005132111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4356207Medicaid
MI950B15004OtherINDIVIDUAL BCBS #
MI0N48730001Medicare PIN
MIT32702Medicare UPIN