Provider Demographics
NPI:1477739266
Name:O'MALLEY CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:O'MALLEY CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:O'MALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:616-392-5600
Mailing Address - Street 1:660 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-5421
Mailing Address - Country:US
Mailing Address - Phone:616-392-5600
Mailing Address - Fax:616-392-2055
Practice Address - Street 1:660 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-5421
Practice Address - Country:US
Practice Address - Phone:616-392-5600
Practice Address - Fax:616-392-2055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2081939111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P11650Medicare PIN