Provider Demographics
NPI:1194981753
Name:KMWA, LLC
Entity type:Organization
Organization Name:KMWA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:LORI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WALENGA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:616-874-8777
Mailing Address - Street 1:6575 BELDING RD NE
Mailing Address - Street 2:SUITE C
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-7418
Mailing Address - Country:US
Mailing Address - Phone:616-874-8777
Mailing Address - Fax:616-874-8835
Practice Address - Street 1:6575 BELDING RD NE
Practice Address - Street 2:SUITE C
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-7418
Practice Address - Country:US
Practice Address - Phone:616-874-8777
Practice Address - Fax:616-874-8835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009047111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty