Healthcare Provider Details

I. General information

NPI: 1508258500
Provider Name (Legal Business Name): GRAND RAPIDS NATURAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2015
Last Update Date: 02/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

638 FULTON STREET W.
GRAND RAPIDS MI
49504
US

IV. Provider business mailing address

638 FULTON STREET W.
GRAND RAPIDS MI
49504
US

V. Phone/Fax

Practice location:
  • Phone: 616-264-5665
  • Fax:
Mailing address:
  • Phone: 616-264-5665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number099.0102887
License Number StateVT

VIII. Authorized Official

Name: DR. KELLY HASSBERGER
Title or Position: OWNER
Credential: N.D.
Phone: 616-264-6556