Healthcare Provider Details

I. General information

NPI: 1023705209
Provider Name (Legal Business Name): EMMA KAY VANDEKIEFT PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2023
Last Update Date: 04/19/2023
Certification Date: 04/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2591 44TH ST SE STE 101
GRAND RAPIDS MI
49512-9094
US

IV. Provider business mailing address

6527 THORNAPPLE RIVER DR SE
ALTO MI
49302-9765
US

V. Phone/Fax

Practice location:
  • Phone: 616-281-9237
  • Fax:
Mailing address:
  • Phone: 616-581-4341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502008302
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: