Healthcare Provider Details

I. General information

NPI: 1346601879
Provider Name (Legal Business Name): JAMES RYAN DIETRICK D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14321 NORTHLAND DR STE 1
BIG RAPIDS MI
49307-2310
US

IV. Provider business mailing address

14321 NORTHLAND DR STE 1
BIG RAPIDS MI
49307-2310
US

V. Phone/Fax

Practice location:
  • Phone: 231-629-8833
  • Fax: 231-629-8834
Mailing address:
  • Phone: 616-916-6753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301010554
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5702
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number2301010554
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: