Healthcare Provider Details

I. General information

NPI: 1518313246
Provider Name (Legal Business Name): CENTRIA HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2016
Last Update Date: 05/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1477 BURKE AVE NE APT B
GRAND RAPIDS MI
49505-5366
US

IV. Provider business mailing address

1477 BURKE AVE NE APT B
GRAND RAPIDS MI
49505-5366
US

V. Phone/Fax

Practice location:
  • Phone: 248-282-3105
  • 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: REBECKA TODD
Title or Position: BEHAVIOR TECH
Credential:
Phone: 248-282-3105