Healthcare Provider Details

I. General information

NPI: 1962828087
Provider Name (Legal Business Name): CHAD UNDERLY L.P.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2014
Last Update Date: 03/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 LEONARD ST NE
GRAND RAPIDS MI
49505-5515
US

IV. Provider business mailing address

2809 PORTER ST SW
GRANDVILLE MI
49418-1144
US

V. Phone/Fax

Practice location:
  • Phone: 616-446-5101
  • Fax:
Mailing address:
  • Phone: 616-446-5101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703103389
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: