Healthcare Provider Details

I. General information

NPI: 1922301274
Provider Name (Legal Business Name): STANDALE CHIROPRACTIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2010
Last Update Date: 01/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 LAKE MICHIGAN DR NW
GRAND RAPIDS MI
49534-4527
US

IV. Provider business mailing address

4310 LEONARD ST NW SUITE 103
WALKER MI
49534-8447
US

V. Phone/Fax

Practice location:
  • Phone: 616-453-3404
  • Fax: 616-453-3418
Mailing address:
  • Phone: 616-453-6329
  • Fax: 616-453-1725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301009732
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. BRANDON J BERG
Title or Position: PHYSICIAN
Credential: DC
Phone: 616-453-3404