Provider Demographics
NPI:1871261644
Name:KOM, MELANIE CECILIA
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:CECILIA
Last Name:KOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-3356
Mailing Address - Country:US
Mailing Address - Phone:269-556-9654
Mailing Address - Fax:
Practice Address - Street 1:2600 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-3356
Practice Address - Country:US
Practice Address - Phone:269-556-9654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-05
Last Update Date:2021-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301011135111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor