Provider Demographics
NPI:1285150888
Name:NORTHWEST CHIROPRACTIC AND SPORTS MEDICINE PLLC
Entity type:Organization
Organization Name:NORTHWEST CHIROPRACTIC AND SPORTS MEDICINE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:DIETRICK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:231-629-8833
Mailing Address - Street 1:2849 S BALDWIN AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49412-7816
Mailing Address - Country:US
Mailing Address - Phone:616-916-6753
Mailing Address - Fax:
Practice Address - Street 1:14321 NORTHLAND DR STE 1
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-2310
Practice Address - Country:US
Practice Address - Phone:231-629-8833
Practice Address - Fax:231-629-8834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-16
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010554111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty