MEDICARE: JS REISTER DC 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	2301009144	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	11553234	OTHER	MI	CAQH
3	95-0D11579-0	OTHER	MI	BCBS

General Provider Information

NPI Number	:	1770644932
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JS REISTER DC PLLC

Provider Business Mailing Address
First Line	:	4310 LEONARD ST NW.
Second Line	:	SUITE 103
City	:	WALKER
State	:	MI
Zip	:	49534-8447
Country	:	US
Telephone Number	:	616-453-6329
Fax Number	:	616-453-1725

Provider Business Practice Location Address
First Line	:	14050 FRUIT RIDGE AVE
Second Line	:
City	:	KENT CITY
State	:	MI
Zip	:	49330-8922
Country	:	US
Telephone Number	:	616-378-5538
Fax Number	:	616-399-4491

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. JEREMY S REISTER
Credential	:	DC
Telephone Number	:	616-378-5538

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	04/27/2016

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