Healthcare Provider Details

I. General information

NPI: 1184409765
Provider Name (Legal Business Name): MALEA ELLENS BS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2023
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 40TH ST SE
GRAND RAPIDS MI
49508-6084
US

IV. Provider business mailing address

1111 40TH ST SE
GRAND RAPIDS MI
49508-6084
US

V. Phone/Fax

Practice location:
  • Phone: 616-885-2039
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: