Healthcare Provider Details

I. General information

NPI: 1649160375
Provider Name (Legal Business Name): LSD CENTER OF EXCELLENCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2025
Last Update Date: 07/04/2025
Certification Date: 07/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WOODLAND PASS STE D
EAST LANSING MI
48823-2000
US

IV. Provider business mailing address

3024 BONITA DR SE
GRAND RAPIDS MI
49508-1424
US

V. Phone/Fax

Practice location:
  • Phone: 616-540-9365
  • Fax:
Mailing address:
  • Phone: 616-540-9365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. KIMBERLY S AGIM
Title or Position: NURSE PRACTITIONER
Credential: ANP-BC
Phone: 616-540-9365