Healthcare Provider Details

I. General information

NPI: 1710378989
Provider Name (Legal Business Name): BREAST HEALTH & WELLNESS CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2015
Last Update Date: 12/15/2023
Certification Date: 12/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 KENMOOR AVE SE STE 201
GRAND RAPIDS MI
49546-8604
US

IV. Provider business mailing address

655 KENMOOR AVE SE STE 201
GRAND RAPIDS MI
49546-8604
US

V. Phone/Fax

Practice location:
  • Phone: 616-920-0825
  • Fax:
Mailing address:
  • Phone: 616-920-0825
  • Fax: 616-920-0830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301070786
License Number StateMI

VIII. Authorized Official

Name: COLLEEN APP
Title or Position: OWNER
Credential: MD
Phone: 616-920-0825