Provider Demographics
NPI:1902928724
Name:MCKENZIE, DOUGLAS GENE (DC)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:GENE
Last Name:MCKENZIE
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 1:3138 BROADMOOR AVE SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49512-1845
Mailing Address - Country:US
Mailing Address - Phone:616-241-4040
Mailing Address - Fax:616-475-6953
Practice Address - Street 1:3138 BROADMOOR AVE SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49512-1845
Practice Address - Country:US
Practice Address - Phone:616-241-4040
Practice Address - Fax:616-475-6953
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008451111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIDM008451OtherBLUE CROSS BLUE SHIELD
MIP27490001Medicare ID - Type Unspecified