Provider Demographics
NPI:1588627657
Name:KOOLEN, RYAN (DC)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:KOOLEN
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 1:9751 E GRAND RIVER AVE
Mailing Address - Street 2:PO BOX 367
Mailing Address - City:PORTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48875-9774
Mailing Address - Country:US
Mailing Address - Phone:517-647-5770
Mailing Address - Fax:517-647-5773
Practice Address - Street 1:9751 E GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:MI
Practice Address - Zip Code:48875-9774
Practice Address - Country:US
Practice Address - Phone:517-647-5770
Practice Address - Fax:517-647-5773
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007736111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N33190Medicare ID - Type Unspecified
MIU78578Medicare UPIN