Healthcare Provider Details

I. General information

NPI: 1467625723
Provider Name (Legal Business Name): PODIATRY WEST SENIOR FOOT CARE SERVICES PLLC
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

56 BENJAMIN AVE SE
GRAND RAPIDS MI
49506-1628
US

IV. Provider business mailing address

56 BENJAMIN AVE SE
GRAND RAPIDS MI
49506-1628
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-9744
  • Fax: 616-451-0717
Mailing address:
  • Phone: 616-456-9744
  • Fax: 616-451-0717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5901001622
License Number StateMI

VIII. Authorized Official

Name: DAVID SMITH
Title or Position: GENERAL MEMBER
Credential: D.P.M.
Phone: 616-456-9744