Provider Demographics
NPI:1659538254
Name:OPTIMAL HEALTH CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:OPTIMAL HEALTH CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRIS
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:616-447-9972
Mailing Address - Street 1:5242 PLAINFIELD NE AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-1084
Mailing Address - Country:US
Mailing Address - Phone:616-447-9972
Mailing Address - Fax:616-447-4140
Practice Address - Street 1:5242 PLAINFIELD NE AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-1084
Practice Address - Country:US
Practice Address - Phone:616-447-9972
Practice Address - Fax:616-447-4140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007742111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4679736Medicaid
MI0N86120Medicare PIN
MI4679736Medicaid