Healthcare Provider Details

I. General information

NPI: 1003126400
Provider Name (Legal Business Name): FS GRAND RAPIDS SOUTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2010
Last Update Date: 10/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6750 KALAMAZOO AVE SE SUITE E
GRAND RAPIDS MI
49508-7897
US

IV. Provider business mailing address

6750 KALAMAZOO AVE SE SUITE E
GRAND RAPIDS MI
49508-7897
US

V. Phone/Fax

Practice location:
  • Phone: 616-698-7200
  • Fax: 616-698-7212
Mailing address:
  • Phone: 616-698-7200
  • Fax: 616-698-7212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberCPED3429
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberCPED3413
License Number StateMI

VIII. Authorized Official

Name: MR. ROBERT L SKINNER JR.
Title or Position: OWNER
Credential: C. PED
Phone: 616-698-7200