Provider Demographics
NPI:1295755361
Name:GRAHAM, ROBERT L (DC)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:GRAHAM
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 1:2230 BRADFORD CT NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-6405
Mailing Address - Country:US
Mailing Address - Phone:616-238-6363
Mailing Address - Fax:
Practice Address - Street 1:2230 BRADFORD CT NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-6405
Practice Address - Country:US
Practice Address - Phone:616-238-6363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2015-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005308111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIRG005308OtherCHIROPRACTOR
MIRG005308Medicaid
MI950D153150OtherCHIROPRACTOR
MIT13536Medicare UPIN
MIRG005308Medicaid