Healthcare Provider Details

I. General information

NPI: 1972315802
Provider Name (Legal Business Name): CHCC GRAND RAPIDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2025
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2984 BRADFORD ST NE
GRAND RAPIDS MI
49525-6427
US

IV. Provider business mailing address

2984 BRADFORD ST NE
GRAND RAPIDS MI
49525-6427
US

V. Phone/Fax

Practice location:
  • Phone: 616-317-8995
  • Fax:
Mailing address:
  • Phone: 616-317-8995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KATHRYN GARRY
Title or Position: DIRECTOR/OFFICER
Credential:
Phone: 248-719-0388