Provider Demographics
NPI:1205234184
Name:GRAND RAPIDS WELLNESS, PC
Entity type:Organization
Organization Name:GRAND RAPIDS WELLNESS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:DEVRIES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:616-233-0960
Mailing Address - Street 1:435 CHERRY ST SE
Mailing Address - Street 2:SUITE B
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4672
Mailing Address - Country:US
Mailing Address - Phone:616-233-0960
Mailing Address - Fax:180-087-1118
Practice Address - Street 1:435 CHERRY ST SE
Practice Address - Street 2:SUITE B
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4672
Practice Address - Country:US
Practice Address - Phone:616-233-0960
Practice Address - Fax:180-087-1118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-09
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009796111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty