Healthcare Provider Details

I. General information

NPI: 1306040746
Provider Name (Legal Business Name): CRYSTAL CHIROPRACTIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 09/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1374 COMMERCIAL AVE SUITE 3
CRYSTAL FALLS MI
49920-1085
US

IV. Provider business mailing address

1374 COMMERCIAL AVE SUITE 3
CRYSTAL FALLS MI
49920-1085
US

V. Phone/Fax

Practice location:
  • Phone: 906-875-3215
  • Fax: 906-874-3215
Mailing address:
  • Phone: 906-875-3215
  • Fax: 906-874-3215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301008438
License Number StateMI

VIII. Authorized Official

Name: DR. LARRY JAY LOEWEN JR.
Title or Position: PRESIDENT
Credential: D.C.
Phone: 906-875-3215