Healthcare Provider Details

I. General information

NPI: 1629437561
Provider Name (Legal Business Name): TRISHA THELEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2016
Last Update Date: 02/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3129 5 MILE RD NE
GRAND RAPIDS MI
49525-1935
US

IV. Provider business mailing address

3129 5 MILE RD NE
GRAND RAPIDS MI
49525-1935
US

V. Phone/Fax

Practice location:
  • Phone: 616-560-2923
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: