Healthcare Provider Details

I. General information

NPI: 1972931749
Provider Name (Legal Business Name): COREY WAYNE KUIPERS PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2013
Last Update Date: 10/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 CONRAN DR
COOPERSVILLE MI
49404-1366
US

IV. Provider business mailing address

364 W 31ST ST
HOLLAND MI
49423-6911
US

V. Phone/Fax

Practice location:
  • Phone: 616-997-6172
  • Fax:
Mailing address:
  • Phone: 616-403-1351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501016433
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: