Healthcare Provider Details

I. General information

NPI: 1124291596
Provider Name (Legal Business Name): RIVER VALLEY ORTHOPEDICS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2008
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 LAFAYETTE AVE SE 4TH FLOOR
GRAND RAPIDS MI
49503-4600
US

IV. Provider business mailing address

350 LAFAYETTE AVE SE 4TH FLOOR
GRAND RAPIDS MI
49503-4600
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-8515
  • Fax:
Mailing address:
  • Phone: 616-456-8515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5901002014
License Number StateMI

VIII. Authorized Official

Name: BOB JOHNSON
Title or Position: MANAGER
Credential:
Phone: 616-459-9404