Healthcare Provider Details

I. General information

NPI: 1548796576
Provider Name (Legal Business Name): NATHAN BIESZKA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3671 SENORA AVE SE
GRAND RAPIDS MI
49508-5501
US

IV. Provider business mailing address

3671 SENORA AVE SE
GRAND RAPIDS MI
49508-5501
US

V. Phone/Fax

Practice location:
  • Phone: 419-439-1218
  • Fax: 616-773-1838
Mailing address:
  • Phone: 419-439-1218
  • Fax: 616-773-1838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: