Healthcare Provider Details

I. General information

NPI: 1811965585
Provider Name (Legal Business Name): KENT NEUROLOGICAL ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 11/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 EAGLE PARK DR NE STE 108
GRAND RAPIDS MI
49525-7057
US

IV. Provider business mailing address

PO BOX 3140
GRAND RAPIDS MI
49501-3140
US

V. Phone/Fax

Practice location:
  • Phone: 616-454-9246
  • Fax: 616-970-6068
Mailing address:
  • Phone: 616-454-9246
  • Fax: 616-970-6068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: DESIDERIO FRANDA INES
Title or Position: OWNER
Credential: MD
Phone: 616-454-9246