Healthcare Provider Details

I. General information

NPI: 1922802248
Provider Name (Legal Business Name): MURAMBYA DESIRE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2025
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3066 LANTANA CT SE
GRAND RAPIDS MI
49512-5373
US

IV. Provider business mailing address

3066 LANTANA CT SE
GRAND RAPIDS MI
49512-5373
US

V. Phone/Fax

Practice location:
  • Phone: 616-690-9339
  • Fax:
Mailing address:
  • Phone: 616-690-9339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberAS410418962
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: