Provider Demographics
NPI:1912096819
Name:SORRELL, RYAN L (DC)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:L
Last Name:SORRELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6208 KALAMAZOO AVE SE STE C
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-7022
Mailing Address - Country:US
Mailing Address - Phone:616-554-0077
Mailing Address - Fax:616-554-0055
Practice Address - Street 1:6208 KALAMAZOO AVE SE STE C
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-7022
Practice Address - Country:US
Practice Address - Phone:616-554-0077
Practice Address - Fax:616-554-0055
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRS008936111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
0P18560Medicare ID - Type Unspecified
MIV05436Medicare UPIN