Provider Demographics
NPI:1649319955
Name:CORONEOS, GEORGE
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:CORONEOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 MIDDLEBORO DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1252
Mailing Address - Country:US
Mailing Address - Phone:616-464-1366
Mailing Address - Fax:
Practice Address - Street 1:3351 CLAYSTONE ST SE
Practice Address - Street 2:G - 15
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5781
Practice Address - Country:US
Practice Address - Phone:616-949-4440
Practice Address - Fax:616-949-3213
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301002674111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D15082Medicare ID - Type UnspecifiedMEDICARE PROVIDER #