Provider Demographics
NPI:1922116458
Name:BRUSVEEN, MARK J (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:BRUSVEEN
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 1:17040 ROBBINS RD
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417
Mailing Address - Country:US
Mailing Address - Phone:616-846-7300
Mailing Address - Fax:616-846-2197
Practice Address - Street 1:17040 ROBBINS RD
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417
Practice Address - Country:US
Practice Address - Phone:616-846-7300
Practice Address - Fax:616-846-2197
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004085111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T33515Medicare UPIN
MION62030Medicare ID - Type Unspecified