Provider Demographics
NPI:1972909794
Name:GRAND RAPIDS APPLIED KINESIOLOGY AND SPORTS CHIROPRACTIC
Entity Type:Organization
Organization Name:GRAND RAPIDS APPLIED KINESIOLOGY AND SPORTS CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:
Authorized Official - Last Name:PLUGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-916-4767
Mailing Address - Street 1:3835 28TH ST SE
Mailing Address - Street 2:STE 102
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-1876
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3835 28TH ST SE
Practice Address - Street 2:STE 102
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-1876
Practice Address - Country:US
Practice Address - Phone:616-916-4767
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3644880302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization