Healthcare Provider Details

I. General information

NPI: 1265771448
Provider Name (Legal Business Name): GRAND RAPIDS PAIN FREE CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2013
Last Update Date: 02/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 FULLER AVE NE
GRAND RAPIDS MI
49503-1901
US

IV. Provider business mailing address

831 FULLER AVE NE
GRAND RAPIDS MI
49503-1901
US

V. Phone/Fax

Practice location:
  • Phone: 616-458-8063
  • Fax: 616-458-6711
Mailing address:
  • Phone: 616-458-8063
  • Fax: 616-458-6711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: MARK RADOM
Title or Position: PRESIDENT
Credential:
Phone: 616-458-8063