Healthcare Provider Details

I. General information

NPI: 1306292354
Provider Name (Legal Business Name): POLLY CAROLE DESTIGTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2016
Last Update Date: 05/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 MADISON AVE SE
GRAND RAPIDS MI
49503-5313
US

IV. Provider business mailing address

515 MADISON AVE SE
GRAND RAPIDS MI
49503-5313
US

V. Phone/Fax

Practice location:
  • Phone: 616-648-8899
  • Fax:
Mailing address:
  • Phone: 616-648-8899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: