Healthcare Provider Details

I. General information

NPI: 1699012104
Provider Name (Legal Business Name): PAUL RELUCIO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2013
Last Update Date: 01/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 CHARLEVOIX DR SE STE. 200
GRAND RAPIDS MI
49546-7085
US

IV. Provider business mailing address

2900 CHARLEVOIX DR SE STE. 200
GRAND RAPIDS MI
49546-7085
US

V. Phone/Fax

Practice location:
  • Phone: 866-588-4299
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberAT 9024
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: