Healthcare Provider Details

I. General information

NPI: 1437518875
Provider Name (Legal Business Name): LIFE SUPPORT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2016
Last Update Date: 02/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5270 NORTHLAND DR NE
GRAND RAPIDS MI
49525-1073
US

IV. Provider business mailing address

PO BOX 10
MASON MI
48854-0010
US

V. Phone/Fax

Practice location:
  • Phone: 616-690-0556
  • Fax:
Mailing address:
  • Phone: 517-676-9788
  • Fax: 517-676-3438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JASON CLAUSER
Title or Position: OWNER
Credential: LMSW
Phone: 616-690-0556