Healthcare Provider Details

I. General information

NPI: 1023274446
Provider Name (Legal Business Name): THE BOUTIQUE AT MERCY HEALTH LACKS CANCER CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2008
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 JEFFERSON AVE SE
GRAND RAPIDS MI
49503-4502
US

IV. Provider business mailing address

200 JEFFERSON AVE SE
GRAND RAPIDS MI
49503-4502
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-5030
  • Fax:
Mailing address:
  • Phone: 616-685-5030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. MATTHEW BIERSACK
Title or Position: PRESIDENT
Credential: MD
Phone: 616-685-6413