Individual
JACOB WARREN KOOISTRA DEVRIES
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
701 E 17TH ST, BLOOMINGTON, IN 47408-1578
(812) 856-4465
Mailing address
4425 HICKORY GROVE BLVD, GREENWOOD, IN 46143-7445
(317) 518-4674
Taxonomy
Speciality
Code
Description
License number
State
390200000X
Student in an Organized Health Care Education/Training Program
Primary
—
—
Other
Enumeration date
01/08/2022
Last updated
01/08/2022
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