Healthcare Provider Details

I. General information

NPI: 1093092140
Provider Name (Legal Business Name): BETHANY CHRISTIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2011
Last Update Date: 11/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 EASTERN AVE NE
GRAND RAPIDS MI
49503-1201
US

IV. Provider business mailing address

901 EASTERN AVE. SE PO BOX 294
GRAND RAPIDS MI
49503
US

V. Phone/Fax

Practice location:
  • Phone: 616-224-7617
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801093691
License Number StateMI

VIII. Authorized Official

Name: JENNIFER POTHOOF
Title or Position: BILLING
Credential:
Phone: 616-224-7617