Provider Demographics
NPI:1780760272
Name:SOPER, LINDA LOUISE (DC)
Entity type:Individual
Prefix:DR
First Name:LINDA
Middle Name:LOUISE
Last Name:SOPER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2740 EASTERN AVE. S.E.
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507
Mailing Address - Country:US
Mailing Address - Phone:616-245-5936
Mailing Address - Fax:
Practice Address - Street 1:2740 EASTERN AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-3643
Practice Address - Country:US
Practice Address - Phone:616-245-5936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004218111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOD15111Medicare ID - Type Unspecified
MIT33024Medicare UPIN