Healthcare Provider Details

I. General information

NPI: 1154470334
Provider Name (Legal Business Name): GREAT LAKES HEARING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6272 28TH ST SE
GRAND RAPIDS MI
49546-6902
US

IV. Provider business mailing address

6272 28TH ST SE
GRAND RAPIDS MI
49546-6902
US

V. Phone/Fax

Practice location:
  • Phone: 616-988-4327
  • Fax: 616-988-9070
Mailing address:
  • Phone: 616-988-4327
  • Fax: 616-988-9070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License Number3501000421
License Number StateMI

VIII. Authorized Official

Name: MRS. NANCY RAE FAASSE'
Title or Position: OWNER
Credential:
Phone: 616-988-4327