Healthcare Provider Details

I. General information

NPI: 1861940686
Provider Name (Legal Business Name): LISA OLMETTI-O'LOUGHLIN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2016
Last Update Date: 09/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 WEALTHY ST SE SUITE 218
GRAND RAPIDS MI
49506-2762
US

IV. Provider business mailing address

2165 TECUMSEH DR SE
GRAND RAPIDS MI
49506-5228
US

V. Phone/Fax

Practice location:
  • Phone: 616-242-0034
  • Fax:
Mailing address:
  • Phone: 616-822-2932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175L00000X
TaxonomyHomeopath
License Number7501002608
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: