Healthcare Provider Details

I. General information

NPI: 1598528242
Provider Name (Legal Business Name): CHARLES DILLON HANLON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2024
Last Update Date: 02/08/2024
Certification Date: 02/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4234 CASCADE RD SE
GRAND RAPIDS MI
49546-8384
US

IV. Provider business mailing address

1801 W BASS LAKE DR
BITELY MI
49309-9322
US

V. Phone/Fax

Practice location:
  • Phone: 616-602-4840
  • Fax:
Mailing address:
  • Phone: 616-260-5433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: