Healthcare Provider Details

I. General information

NPI: 1821465956
Provider Name (Legal Business Name): GRAND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2015
Last Update Date: 06/20/2021
Certification Date: 06/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 KENMOOR AVE SE STE H
GRAND RAPIDS MI
49546-2391
US

IV. Provider business mailing address

1531 LAKE GROVE AVE SE
EAST GRAND RAPIDS MI
49506-4741
US

V. Phone/Fax

Practice location:
  • Phone: 616-466-4175
  • Fax: 616-259-4855
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number5401000137
License Number StateMI

VIII. Authorized Official

Name: MS. VIKKI NESTICO
Title or Position: ACUPUNCTURIST
Credential: L. AC.
Phone: 917-376-4001