Healthcare Provider Details

I. General information

NPI: 1386633675
Provider Name (Legal Business Name): ALLENDALE FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11160 WJ PRESLEY PKWY STE 101
ALLENDALE MI
49401-8075
US

IV. Provider business mailing address

11160 WJ PRESLEY PKWY STE 101
ALLENDALE MI
49401-8075
US

V. Phone/Fax

Practice location:
  • Phone: 616-895-2000
  • Fax: 616-895-2009
Mailing address:
  • Phone: 616-895-2000
  • Fax: 616-895-2009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BRENDA SMOCK
Title or Position: BILLING MANAGER
Credential:
Phone: 616-895-2000