Healthcare Provider Details

I. General information

NPI: 1720800204
Provider Name (Legal Business Name): MR. COLIN DANIEL JAMES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 BALL AVE
GRAND RAPIDS MI
49505
US

IV. Provider business mailing address

324 SWEET ST NE
GRAND RAPIDS MI
49505
US

V. Phone/Fax

Practice location:
  • Phone: 616-430-2956
  • Fax:
Mailing address:
  • Phone: 616-617-1351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: