Healthcare Provider Details

I. General information

NPI: 1588627657
Provider Name (Legal Business Name): RYAN KOOLEN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 09/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9751 E GRAND RIVER AVE
PORTLAND MI
48875-9774
US

IV. Provider business mailing address

9751 E GRAND RIVER AVE PO BOX 367
PORTLAND MI
48875-9774
US

V. Phone/Fax

Practice location:
  • Phone: 517-647-5770
  • Fax: 517-647-5773
Mailing address:
  • Phone: 517-647-5770
  • Fax: 517-647-5773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301007736
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: