Healthcare Provider Details

I. General information

NPI: 1053901314
Provider Name (Legal Business Name): HAVEN SPINE & PAIN CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2021
Last Update Date: 12/09/2021
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2680 LEONARD ST NE STE 3
GRAND RAPIDS MI
49525-6902
US

IV. Provider business mailing address

2680 LEONARD ST NE STE 3
GRAND RAPIDS MI
49525-6902
US

V. Phone/Fax

Practice location:
  • Phone: 616-364-4200
  • Fax: 616-364-7347
Mailing address:
  • Phone: 616-364-4200
  • Fax: 616-364-7347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JACK DILLON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 312-505-1033