MEDICARE: KB CHIROPRACTIC PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1033423926
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KB CHIROPRACTIC PLLC

Provider Business Mailing Address
First Line	:	4110 LAKE MICHIGAN DR NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49534-4527
Country	:	US
Telephone Number	:	616-502-8458
Fax Number	:

Provider Business Practice Location Address
First Line	:	4110 LAKE MICHIGAN DR NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49534-4527
Country	:	US
Telephone Number	:	616-502-8458
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN/CEO
Name	:	DR. KELLEN I BRUSVEEN
Credential	:	D.C.
Telephone Number	:	616-502-8468

Provider Enumeration Date	:	08/03/2010
Last Update Date	:	08/03/2010

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