Healthcare Provider Details

I. General information

NPI: 1386910826
Provider Name (Legal Business Name): EUGENE MARTIN KOON LBSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2012
Last Update Date: 03/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 SHELDON BLVD SE
GRAND RAPIDS MI
49503-4513
US

IV. Provider business mailing address

2401 SHARON AVE SW
WYOMING MI
49519-2223
US

V. Phone/Fax

Practice location:
  • Phone: 616-965-8200
  • Fax: 616-242-6057
Mailing address:
  • Phone: 616-965-8200
  • Fax: 616-242-6057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802084210
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: