Provider Demographics
NPI:1700124237
Name:LIETZ CHIROPRACTIC AND APPLIED KINESIOLOGY LLC
Entity Type:Organization
Organization Name:LIETZ CHIROPRACTIC AND APPLIED KINESIOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:LIETZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:616-530-3333
Mailing Address - Street 1:3550 FAIRLANES AVE SW
Mailing Address - Street 2:SUITE B
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1572
Mailing Address - Country:US
Mailing Address - Phone:616-530-3333
Mailing Address - Fax:616-608-3803
Practice Address - Street 1:3550 FAIRLANES AVE SW
Practice Address - Street 2:SUITE B
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1572
Practice Address - Country:US
Practice Address - Phone:616-530-3333
Practice Address - Fax:616-608-3803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-17
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL2083320111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty