Provider Demographics
NPI:1487701108
Name:VERMEULEN, LISA MARIE (DC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:VERMEULEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:4535 3 MILE RD NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9331
Mailing Address - Country:US
Mailing Address - Phone:616-551-5433
Mailing Address - Fax:616-301-2630
Practice Address - Street 1:4535 3 MILE RD NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9331
Practice Address - Country:US
Practice Address - Phone:616-551-5433
Practice Address - Fax:616-301-2630
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009195111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI11668114OtherCAQH PROVIDER ID