Basic Information
| Provider Information | |||||||||
| NPI: | 1386641884 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERRAULT | ||||||||
| FirstName: | KIRBY | ||||||||
| MiddleName: | KENNETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DC | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2199 JOLLY RD | ||||||||
| Address2: | SUITE # 140 | ||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488643968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173811880 | ||||||||
| FaxNumber: | 5173811990 | ||||||||
| Practice Location | |||||||||
| Address1: | 2199 JOLLY RD | ||||||||
| Address2: | SUITE # 140 | ||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488643968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173811880 | ||||||||
| FaxNumber: | 5173811990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 07/08/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/17/2006 | ||||||||
| NPIReactivationDate: | 03/27/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 2301007563 | MI | Y | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 950C350 750 | 01 | MI | BCBS PIN | OTHER |