Provider Demographics
NPI:1417943036
Name:KOOISTRA, CHARLES SCOTT (DC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:SCOTT
Last Name:KOOISTRA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICK002664111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
950D150810OtherBCBS
350058662Medicare ID - Type Unspecified
0D15081Medicare ID - Type Unspecified
950D150810OtherBCBS