Healthcare Provider Details

I. General information

NPI: 1043050081
Provider Name (Legal Business Name): OPTALIS GRAND RAPIDS OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2024
Last Update Date: 06/04/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 32ND ST SE
GRAND RAPIDS MI
49508-7909
US

IV. Provider business mailing address

25500 MEADOWBROOK RD STE 230
NOVI MI
48375-1882
US

V. Phone/Fax

Practice location:
  • Phone: 616-452-5900
  • Fax: 615-645-2427
Mailing address:
  • Phone: 248-277-5724
  • Fax: 248-692-4356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MARIANNE CONNER
Title or Position: VP FINANCE
Credential:
Phone: 248-277-5724