Healthcare Provider Details

I. General information

NPI: 1659283505
Provider Name (Legal Business Name): NIKI STAHL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: NICK STAHL

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 BALL AVE NE
GRAND RAPIDS MI
49505-5904
US

IV. Provider business mailing address

11820 WOODSIDE DR
MIDDLEVILLE MI
49333-9782
US

V. Phone/Fax

Practice location:
  • Phone: 269-804-5329
  • Fax:
Mailing address:
  • Phone: 269-804-5329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: