Healthcare Provider Details

I. General information

NPI: 1245509348
Provider Name (Legal Business Name): FMS CLYDE PARK SOUTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5311 CLYDE PARK AVE SW
GRAND RAPIDS MI
49509-9527
US

IV. Provider business mailing address

5311 CLYDE PARK AVE SW
GRAND RAPIDS MI
49509-9527
US

V. Phone/Fax

Practice location:
  • Phone: 616-534-7179
  • Fax: 616-534-7930
Mailing address:
  • Phone: 616-534-7179
  • Fax: 616-534-7930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BARRY L. BLANTON
Title or Position: VICE PRESIDENT
Credential:
Phone: 781-699-9000