Provider Demographics
NPI:1710975370
Name:AAMODT, WAYNE GARTH (DC)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:GARTH
Last Name:AAMODT
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 1:1805 44TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-5005
Mailing Address - Country:US
Mailing Address - Phone:616-455-4200
Mailing Address - Fax:616-455-4201
Practice Address - Street 1:1805 44TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-5005
Practice Address - Country:US
Practice Address - Phone:616-455-4200
Practice Address - Fax:616-455-4201
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004756111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10888236OtherCAQH
MI10888236OtherCAQH