Healthcare Provider Details

I. General information

NPI: 1477026847
Provider Name (Legal Business Name): VETGR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2019
Last Update Date: 01/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 MONROE CENTER ST NW STE 504
GRAND RAPIDS MI
49503-2903
US

IV. Provider business mailing address

77 MONROE CENTER ST NW STE 504
GRAND RAPIDS MI
49503-2903
US

V. Phone/Fax

Practice location:
  • Phone: 616-226-6435
  • Fax:
Mailing address:
  • Phone: 616-226-6435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID R BEACH
Title or Position: MENTAL HEALTH DIRECTOR
Credential: DMIN
Phone: 616-226-6435