Healthcare Provider Details

I. General information

NPI: 1225728736
Provider Name (Legal Business Name): SPORT AND INJURY CLINICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2023
Last Update Date: 05/09/2023
Certification Date: 05/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1116 COVELL AVE NW
GRAND RAPIDS MI
49504-3816
US

IV. Provider business mailing address

1116 COVELL AVE NW
GRAND RAPIDS MI
49504-3816
US

V. Phone/Fax

Practice location:
  • Phone: 616-676-6939
  • Fax:
Mailing address:
  • Phone: 616-676-6939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ADAM JAMES GELLER
Title or Position: OWNER
Credential: PHYSICIAN ASSISTANT
Phone: 616-676-6939