Provider Demographics
NPI:1619309218
Name:GENESIS CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:GENESIS CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:KAPUT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:586-604-3253
Mailing Address - Street 1:21880 23 MILE RD
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-4422
Mailing Address - Country:US
Mailing Address - Phone:586-604-3253
Mailing Address - Fax:
Practice Address - Street 1:21880 23 MILE RD
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48042-4422
Practice Address - Country:US
Practice Address - Phone:586-604-3253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009884111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1861767238Medicare NSC