Healthcare Provider Details

I. General information

NPI: 1104934496
Provider Name (Legal Business Name): KELLI ANNE WILCOX-DEGRAAF DC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2006
Last Update Date: 08/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 ALPINE AVE NW
COMSTOCK PARK MI
49321-9717
US

IV. Provider business mailing address

5900 ALPINE AVE NW
COMSTOCK PARK MI
49321-9717
US

V. Phone/Fax

Practice location:
  • Phone: 616-784-5433
  • Fax: 616-784-3577
Mailing address:
  • Phone: 616-784-5433
  • Fax: 616-784-3577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301009030
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: