Healthcare Provider Details

I. General information

NPI: 1023680964
Provider Name (Legal Business Name): GREG ALLEN BOOTH VANDER WEL LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 BALTIMORE DR NE
GRAND RAPIDS MI
49503-3934
US

IV. Provider business mailing address

470 BALTIMORE DR NE
GRAND RAPIDS MI
49503-3934
US

V. Phone/Fax

Practice location:
  • Phone: 616-726-1909
  • Fax:
Mailing address:
  • Phone: 616-726-1909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703114773
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: