Healthcare Provider Details

I. General information

NPI: 1376304154
Provider Name (Legal Business Name): SERGIO CHAVEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2024
Last Update Date: 01/19/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 PEARL ST NW STE 200
GRAND RAPIDS MI
49503-3026
US

IV. Provider business mailing address

40 PEARL ST NW STE 200
GRAND RAPIDS MI
49503-3026
US

V. Phone/Fax

Practice location:
  • Phone: 616-204-7006
  • Fax:
Mailing address:
  • Phone: 616-204-7006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: