Healthcare Provider Details

I. General information

NPI: 1417943036
Provider Name (Legal Business Name): CHARLES SCOTT KOOISTRA DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 02/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2855 BYRON CENTER AVE SW
WYOMING MI
49519-2415
US

IV. Provider business mailing address

2855 BYRON CENTER AVE SW
WYOMING MI
49519-2415
US

V. Phone/Fax

Practice location:
  • Phone: 616-532-2518
  • Fax: 616-532-2696
Mailing address:
  • Phone: 616-532-2518
  • Fax: 616-532-2696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCK002664
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: