Provider Demographics
NPI:1770644932
Name:JS REISTER DC PLLC
Entity type:Organization
Organization Name:JS REISTER DC PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:S
Authorized Official - Last Name:REISTER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:616-378-5538
Mailing Address - Street 1:4310 LEONARD ST NW.
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WALKER
Mailing Address - State:MI
Mailing Address - Zip Code:49534-8447
Mailing Address - Country:US
Mailing Address - Phone:616-453-6329
Mailing Address - Fax:616-453-1725
Practice Address - Street 1:14050 FRUIT RIDGE AVE
Practice Address - Street 2:
Practice Address - City:KENT CITY
Practice Address - State:MI
Practice Address - Zip Code:49330-8922
Practice Address - Country:US
Practice Address - Phone:616-378-5538
Practice Address - Fax:616-399-4491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009144111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4873635 TYPE 14Medicaid
MI11553234OtherCAQH
MI95-0D11579-0OtherBCBS
MI0P28350Medicare ID - Type Unspecified
MIV08428Medicare UPIN