Provider Demographics
NPI:1720486293
Name:KINGSBURY CHIROPRACTIC LC
Entity Type:Organization
Organization Name:KINGSBURY CHIROPRACTIC LC
Other - Org Name:DR. CRAIG ALAN KINGSBURY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:KINGSBURY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:616-283-2445
Mailing Address - Street 1:640 OLD ORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4453
Mailing Address - Country:US
Mailing Address - Phone:616-283-2445
Mailing Address - Fax:
Practice Address - Street 1:84 E LAKEWOOD BLVD
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-2000
Practice Address - Country:US
Practice Address - Phone:616-392-2166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-15
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008835111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty