Provider Demographics
NPI:1396018446
Name:KOOISTRA CHIROPRACTIC CLINIC PLLC
Entity Type:Organization
Organization Name:KOOISTRA CHIROPRACTIC CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:C
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:KOOISTRA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:616-532-2518
Mailing Address - Street 1:2855 BYRON CENTER AVE SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-2415
Mailing Address - Country:US
Mailing Address - Phone:616-532-2518
Mailing Address - Fax:616-532-2696
Practice Address - Street 1:2855 BYRON CENTER AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-2415
Practice Address - Country:US
Practice Address - Phone:616-532-2518
Practice Address - Fax:616-532-2696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1496111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty