Healthcare Provider Details

I. General information

NPI: 1417927427
Provider Name (Legal Business Name): JEREMY S REISTER DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 04/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14050 FRUIT RIDGE AVE
KENT CITY MI
49330-8922
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 616-378-5538
  • Fax: 616-399-4491
Mailing address:
  • Phone: 616-453-6329
  • Fax: 616-453-1725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301009144
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: