Healthcare Provider Details

I. General information

NPI: 1366956583
Provider Name (Legal Business Name): MALIBU GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2017
Last Update Date: 11/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5258 PLAINFIELD AVE NE
GRAND RAPIDS MI
49525-1092
US

IV. Provider business mailing address

4075 YARROW DR NE
GRAND RAPIDS MI
49525-9531
US

V. Phone/Fax

Practice location:
  • Phone: 616-635-2398
  • Fax:
Mailing address:
  • Phone:
  • 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: CORINN NICHOLS
Title or Position: MANAGER
Credential:
Phone: 616-450-4125