Healthcare Provider Details

I. General information

NPI: 1457624942
Provider Name (Legal Business Name): KEVIN FREDERICK CHURCHILL DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2012
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 E BELTLINE NE SUITE 200
GRAND RAPIDS MI
49525
US

IV. Provider business mailing address

PO BOX 30516 DEPT 5300
LANSING MI
48909
US

V. Phone/Fax

Practice location:
  • Phone: 616-365-2709
  • Fax: 616-785-1201
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501015557
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: