Provider Demographics
NPI:1518026822
Name:GRISWOLD, KEVIN MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MICHAEL
Last Name:GRISWOLD
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 1:19201 ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48183-1064
Mailing Address - Country:US
Mailing Address - Phone:734-479-4325
Mailing Address - Fax:
Practice Address - Street 1:19201 ALLEN RD
Practice Address - Street 2:
Practice Address - City:BROWNSTOWN TWP
Practice Address - State:MI
Practice Address - Zip Code:48183-1064
Practice Address - Country:US
Practice Address - Phone:734-479-4325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004613111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0Q25080Medicare ID - Type Unspecified
MIT33837Medicare UPIN