Healthcare Provider Details

I. General information

NPI: 1487301669
Provider Name (Legal Business Name): JON LEE TUNNEY LLC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: ELLE TUNNEY LLC

II. Dates (important events)

Enumeration Date: 03/07/2022
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MONROE AVE NW
GRAND RAPIDS MI
49503-1455
US

IV. Provider business mailing address

1115 PETOSKEY ST
PETOSKEY MI
49770
US

V. Phone/Fax

Practice location:
  • Phone: 616-259-7207
  • Fax: 616-259-7261
Mailing address:
  • Phone: 231-519-0070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6451022130
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: