Healthcare Provider Details

I. General information

NPI: 1538774849
Provider Name (Legal Business Name): GRACE MIERENDORF LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2770 E BELTLINE AVE NE
GRAND RAPIDS MI
49525-8614
US

IV. Provider business mailing address

820 MEADOW DR
WAYLAND MI
49348-1369
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-7000
  • Fax:
Mailing address:
  • Phone: 269-680-9159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601002645
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: