Provider Demographics
NPI:1407382963
Name:CONN CHIROPRACTIC CLINIC, PLLC
Entity Type:Organization
Organization Name:CONN CHIROPRACTIC CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:CONN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:616-855-0510
Mailing Address - Street 1:3097 29TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-1726
Mailing Address - Country:US
Mailing Address - Phone:616-855-0510
Mailing Address - Fax:855-710-7034
Practice Address - Street 1:3097 29TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-1726
Practice Address - Country:US
Practice Address - Phone:616-855-0510
Practice Address - Fax:855-710-7034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010529111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty