Provider Demographics
NPI:1417328659
Name:NOVO CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:NOVO CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:P
Authorized Official - Last Name:KONYNENBELT
Authorized Official - Suffix:
Authorized Official - Credentials:DC, MS
Authorized Official - Phone:616-259-9835
Mailing Address - Street 1:5570 WILSON AVE SW
Mailing Address - Street 2:STE L
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49418-8867
Mailing Address - Country:US
Mailing Address - Phone:616-259-9835
Mailing Address - Fax:
Practice Address - Street 1:5570 WILSON AVE SW
Practice Address - Street 2:STE L
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49418-8867
Practice Address - Country:US
Practice Address - Phone:616-259-9835
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-14
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010372111N00000X
MI2301010340111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty