Provider Demographics
NPI:1629015946
Name:KWAST, MICHAEL L (DC, CSCS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:KWAST
Suffix:
Gender:M
Credentials:DC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 E BELTLINE AVE NE
Mailing Address - Street 2:SUITE #3
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9715
Mailing Address - Country:US
Mailing Address - Phone:616-447-9888
Mailing Address - Fax:616-447-9886
Practice Address - Street 1:4150 E BELTLINE AVE NE
Practice Address - Street 2:SUITE #3
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9715
Practice Address - Country:US
Practice Address - Phone:616-447-9888
Practice Address - Fax:616-447-9886
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMK007656111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4073990Medicaid
MI0P39340Medicare PIN