Healthcare Provider Details

I. General information

NPI: 1154583078
Provider Name (Legal Business Name): CRESTON MEDICAL CENTER, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2008
Last Update Date: 07/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 PLAINFIELD AVE NE
GRAND RAPIDS MI
49505-4913
US

IV. Provider business mailing address

PO BOX 2564
GRAND RAPIDS MI
49501-2564
US

V. Phone/Fax

Practice location:
  • Phone: 616-776-1275
  • Fax: 616-776-3713
Mailing address:
  • Phone: 616-776-1275
  • Fax: 616-776-3713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number4301029675
License Number StateMI

VIII. Authorized Official

Name: DR. MARGO MARYLAND APP
Title or Position: ADMINISTRATOR
Credential: PHD
Phone: 616-776-0814