Provider Demographics
NPI:1891096699
Name:DC HEALTHY LIVING CENTER
Entity Type:Organization
Organization Name:DC HEALTHY LIVING CENTER
Other - Org Name:DC CHIROPRACTIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:KWOK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:616-301-2225
Mailing Address - Street 1:1100 4 MILE RD NW
Mailing Address - Street 2:SUITE D
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49544-7397
Mailing Address - Country:US
Mailing Address - Phone:616-301-2225
Mailing Address - Fax:616-719-4593
Practice Address - Street 1:1100 4 MILE RD NW
Practice Address - Street 2:SUITE D
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-7397
Practice Address - Country:US
Practice Address - Phone:616-301-2225
Practice Address - Fax:616-719-4593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-10
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009220111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION19530004Medicare PIN