Healthcare Provider Details

I. General information

NPI: 1285104224
Provider Name (Legal Business Name): MRS. MAYELA GUADALUPE ROSALES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2018
Last Update Date: 12/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 MONROE AVE NW STE 140
GRAND RAPIDS MI
49505-4609
US

IV. Provider business mailing address

6420 RIDGEMONT DR SE
GRAND RAPIDS MI
49546-9218
US

V. Phone/Fax

Practice location:
  • Phone: 616-458-9520
  • Fax:
Mailing address:
  • Phone: 956-648-7510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: