Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 08001705A | IN |
NPI | 1003810060 |
---|---|
Provider Name | Dr. Trent Michael Anderson |
First Address | Bloomington, IN 47401-5550 |
Second Address | Bloomington, IN 47401-5550 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/06/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U64956 | (02) | IN |