Healthcare Provider Details

I. General information

NPI: 1306204565
Provider Name (Legal Business Name): STACY GARRETT B.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACY SHORT

II. Dates (important events)

Enumeration Date: 02/03/2016
Last Update Date: 02/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 BALL AVE NE
GRAND RAPIDS MI
49505-5904
US

IV. Provider business mailing address

1101 BALL AVE NE
GRAND RAPIDS MI
49505-5904
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-6571
  • Fax:
Mailing address:
  • Phone: 616-456-6571
  • 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: