Healthcare Provider Details

I. General information

NPI: 1235092131
Provider Name (Legal Business Name): JACK C METIVA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6694 S M 88 HWY
BELLAIRE MI
49615-9296
US

IV. Provider business mailing address

6694 S M 88 HWY
BELLAIRE MI
49615-9296
US

V. Phone/Fax

Practice location:
  • Phone: 616-481-1947
  • Fax:
Mailing address:
  • Phone: 616-481-1947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2279C0205X
TaxonomyCritical Care Registered Respiratory Therapist
License Number95018
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: