Healthcare Provider Details

I. General information

NPI: 1780077446
Provider Name (Legal Business Name): PETER SABIITI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2015
Last Update Date: 03/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 BALL AVE NE
GRAND RAPIDS MI
49505-5904
US

IV. Provider business mailing address

1197 STONEBROOK CT NE
GRAND RAPIDS MI
49505-7220
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-6395
  • Fax:
Mailing address:
  • Phone: 706-589-1756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number054559748
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: