Healthcare Provider Details

I. General information

NPI: 1053570499
Provider Name (Legal Business Name): MED1
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2008
Last Update Date: 06/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 MONROE AVE NW SUITE 150
GRAND RAPIDS MI
49503-1055
US

IV. Provider business mailing address

1140 MONROE AVE NW SUITE 150
GRAND RAPIDS MI
49503-1055
US

V. Phone/Fax

Practice location:
  • Phone: 616-459-6331
  • Fax:
Mailing address:
  • Phone: 616-459-6331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number5501011266
License Number StateMI

VIII. Authorized Official

Name: MRS. MARY ALICE EHRLICH
Title or Position: EXECUTIVE VICE PRESIDENT
Credential: RN,BSN,MS
Phone: 616-459-6331