Healthcare Provider Details

I. General information

NPI: 1609046184
Provider Name (Legal Business Name): VASAIO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2008
Last Update Date: 08/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E PARIS AVE SE
GRAND RAPIDS MI
49546-8367
US

IV. Provider business mailing address

1100 E PARIS AVE SE
GRAND RAPIDS MI
49546-8367
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-2966
  • Fax:
Mailing address:
  • Phone: 616-942-2966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number5101012967
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number5101012967
License Number StateMI

VIII. Authorized Official

Name: VICKIE BENNETT
Title or Position: OWNER
Credential:
Phone: 616-942-2966