Healthcare Provider Details

I. General information

NPI: 1598164667
Provider Name (Legal Business Name): ERIC BROADWORTH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 MARKET AVE SW # 106
GRAND RAPIDS MI
49503-4029
US

IV. Provider business mailing address

1139 HOUSEMAN AVE NE
GRAND RAPIDS MI
49503-1229
US

V. Phone/Fax

Practice location:
  • Phone: 616-757-0932
  • Fax: 616-259-4226
Mailing address:
  • Phone: 810-347-5219
  • Fax: 616-259-4226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501016918
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: