Provider Demographics
NPI:1457008559
Name:MIDWEST CHIROPRACTIC AND REHAB LLC
Entity Type:Organization
Organization Name:MIDWEST CHIROPRACTIC AND REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:LOGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KETCHUM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:269-492-8795
Mailing Address - Street 1:24285 RED ARROW HWY STE A
Mailing Address - Street 2:
Mailing Address - City:MATTAWAN
Mailing Address - State:MI
Mailing Address - Zip Code:49071-7700
Mailing Address - Country:US
Mailing Address - Phone:269-399-4690
Mailing Address - Fax:
Practice Address - Street 1:24285 RED ARROW HWY STE A
Practice Address - Street 2:
Practice Address - City:MATTAWAN
Practice Address - State:MI
Practice Address - Zip Code:49071-7700
Practice Address - Country:US
Practice Address - Phone:269-492-8795
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-08
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty