Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 2301008438 | MI |
N | 111NR0400X | Rehabilitation Chiropractor | 2301008438 | MI |
N | 111NS0005X | Chiropractic Sports Physician | 2301008438 | MI |
N | 111NX0100X | Occupational Health | 2301008438 | MI |
N | 111NX0800X | Chiropractor Orthopedic Specialist | 2301008438 | MI |
NPI | 1609095496 |
---|---|
Provider Name | Dr. Larry Jay Loewen JR. |
First Address | Crystal Falls, MI 49920-1085 |
Second Address | Crystal Falls, MI 49920-1085 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/04/2007 |
Last Update Date | 27/10/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
950D75037 | BLUE CROSS BLUE SHIELD (01) | MI |