Healthcare Provider Details

I. General information

NPI: 1184509804
Provider Name (Legal Business Name): DANIEL KOMLA BORTI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2025
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 MONROE AVE NW STE 629
GRAND RAPIDS MI
49505-4671
US

IV. Provider business mailing address

2752 ROYAL POINT DR NW
GRAND RAPIDS MI
49534-1354
US

V. Phone/Fax

Practice location:
  • Phone: 616-512-3210
  • Fax: 855-231-2592
Mailing address:
  • Phone: 307-343-6831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: