Healthcare Provider Details

I. General information

NPI: 1194798959
Provider Name (Legal Business Name): EAST PARIS SURGICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E PARIS AVE SE SUITE LL01
GRAND RAPIDS MI
49546-3680
US

IV. Provider business mailing address

1000 E PARIS AVE SE SUITE LL01
GRAND RAPIDS MI
49546-3680
US

V. Phone/Fax

Practice location:
  • Phone: 616-464-3430
  • Fax: 616-464-3440
Mailing address:
  • Phone: 616-464-3430
  • Fax: 616-464-3440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number416834
License Number StateMI

VIII. Authorized Official

Name: KATHY J MOSLEY
Title or Position: FACILITY ADMINISTRATOR
Credential: BS
Phone: 616-949-2001