Healthcare Provider Details

I. General information

NPI: 1700967106
Provider Name (Legal Business Name): EBSC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 01/03/2021
Certification Date: 01/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 EAST BELTLINE NE
GRAND RAPIDS MI
49525-6049
US

IV. Provider business mailing address

750 EAST BELTLINE NE
GRAND RAPIDS MI
49525-6049
US

V. Phone/Fax

Practice location:
  • Phone: 616-940-3600
  • Fax: 616-954-0213
Mailing address:
  • Phone: 616-940-3600
  • Fax: 616-954-0216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. KRISTINE PATRICE KILGORE
Title or Position: ADMINISTRATICE DIRECTOR
Credential: RN BSN
Phone: 616-580-6520