Healthcare Provider Details

I. General information

NPI: 1083470454
Provider Name (Legal Business Name): JAMES WILLEM ALEXANDER VAN DUIJVENBOODE VARKEVISSER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2024
Last Update Date: 08/21/2024
Certification Date: 02/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1939 DIVISION AVE. S
GRAND RAPIDS MI
49507
US

IV. Provider business mailing address

1939 DIVISION AVE. S
GRAND RAPIDS MI
49507
US

V. Phone/Fax

Practice location:
  • Phone: 616-247-3815
  • Fax: 616-245-0450
Mailing address:
  • Phone: 616-247-3815
  • Fax: 616-245-0450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: