Healthcare Provider Details

I. General information

NPI: 1043288467
Provider Name (Legal Business Name): GRAND RIVER ENDOSCOPY CENTER, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 10/25/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 LAFAYETTE AVE SE SUITE 200
GRAND RAPIDS MI
49503-4693
US

IV. Provider business mailing address

310 LAFAYETTE AVE SE SUITE 200
GRAND RAPIDS MI
49503-4693
US

V. Phone/Fax

Practice location:
  • Phone: 616-752-5890
  • Fax:
Mailing address:
  • Phone: 616-752-5890
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: HOLLY SUND
Title or Position: ACCESS ASC BILLING TEAM LEAD
Credential:
Phone: 616-685-7174