Provider Demographics
NPI:1598760167
Name:O'MALLEY, BRENDA (DC)
Entity Type:Individual
Prefix:MISS
First Name:BRENDA
Middle Name:
Last Name:O'MALLEY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:399 E 32ND ST
Mailing Address - Street 2:STE 30
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-5518
Mailing Address - Country:US
Mailing Address - Phone:616-392-5600
Mailing Address - Fax:616-392-2055
Practice Address - Street 1:399 E 32ND ST
Practice Address - Street 2:STE 30
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-5518
Practice Address - Country:US
Practice Address - Phone:616-392-5600
Practice Address - Fax:616-392-2055
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008919111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0G011280OtherBCBSM
MI0G011280OtherBCBSM