Healthcare Provider Details

I. General information

NPI: 1164538286
Provider Name (Legal Business Name): SIXTY FOURTH STREET LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2373 64TH ST SW SUITE 2200
BYRON CENTER MI
49315-7974
US

IV. Provider business mailing address

2373 64TH ST SW SUITE 2200
BYRON CENTER MI
49315-7974
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-3975
  • Fax: 616-685-3977
Mailing address:
  • Phone: 616-685-3975
  • Fax: 616-685-3977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANDREW LIVINGSTON
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 616-685-3975