Healthcare Provider Details

I. General information

NPI: 1053936161
Provider Name (Legal Business Name): KENDRA-MARIE MADDISON GARCIA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 PLYMOUTH AVE NE
GRAND RAPIDS MI
49505-6028
US

IV. Provider business mailing address

424 PLYMOUTH AVE NE
GRAND RAPIDS MI
49505-6028
US

V. Phone/Fax

Practice location:
  • Phone: 833-328-8476
  • Fax:
Mailing address:
  • Phone: 833-328-8476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4351046736
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: