Provider Demographics
NPI:1659614501
Name:WILLIAMSTON SPORT AND SPINE CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:WILLIAMSTON SPORT AND SPINE CHIROPRACTIC CLINIC
Other - Org Name:WILLIAMSTON SPORT AND SPINE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:ZIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:989-721-6878
Mailing Address - Street 1:425 W GRAND RIVER AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:WILLIAMSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48895-1343
Mailing Address - Country:US
Mailing Address - Phone:517-655-2468
Mailing Address - Fax:517-655-5678
Practice Address - Street 1:425 W GRAND RIVER AVE
Practice Address - Street 2:SUITE D
Practice Address - City:WILLIAMSTON
Practice Address - State:MI
Practice Address - Zip Code:48895-1343
Practice Address - Country:US
Practice Address - Phone:517-655-2468
Practice Address - Fax:517-655-5678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-28
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009865111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty