Healthcare Provider Details

I. General information

NPI: 1902031057
Provider Name (Legal Business Name): KIMBERLY RACHEL MELES D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 02/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1787 GRAND RIDGE CT NE STE 101
GRAND RAPIDS MI
49525
US

IV. Provider business mailing address

5900 BYRON CENTER AVE SW
WYOMING MI
49519-9606
US

V. Phone/Fax

Practice location:
  • Phone: 616-252-4540
  • Fax:
Mailing address:
  • Phone: 616-252-3243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberUO2117
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5101022161
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: