Provider Demographics
NPI:1750642997
Name:CRAIG S ROCKWELL DC PLLC
Entity Type:Organization
Organization Name:CRAIG S ROCKWELL DC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:ROCKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:616-457-4511
Mailing Address - Street 1:7579 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428-9251
Mailing Address - Country:US
Mailing Address - Phone:616-457-4511
Mailing Address - Fax:616-667-1936
Practice Address - Street 1:7579 MAIN ST
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-9251
Practice Address - Country:US
Practice Address - Phone:616-457-4511
Practice Address - Fax:616-667-1936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004746320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOGO5044Medicare PIN