Healthcare Provider Details

I. General information

NPI: 1144091927
Provider Name (Legal Business Name): DAVID SAMUEL HARRISON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2024
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2870 E BELTLINE AVE NE
GRAND RAPIDS MI
49525-9704
US

IV. Provider business mailing address

2870 E BELTLINE AVE NE
GRAND RAPIDS MI
49525-9704
US

V. Phone/Fax

Practice location:
  • Phone: 616-363-0902
  • Fax: 616-363-9730
Mailing address:
  • Phone: 616-363-0902
  • Fax: 616-363-9730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0900X
TaxonomyInternist Chiropractor
License Number2301401470
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: