Provider Demographics
NPI:1902355076
Name:WOLTERS, BRIAN JACOB (DC)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:JACOB
Last Name:WOLTERS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7579 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428
Mailing Address - Country:US
Mailing Address - Phone:616-457-4511
Mailing Address - Fax:616-667-1936
Practice Address - Street 1:7579 MAIN STREET
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428
Practice Address - Country:US
Practice Address - Phone:616-457-4511
Practice Address - Fax:616-667-1936
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-29
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010407111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor