Healthcare Provider Details

I. General information

NPI: 1164734364
Provider Name (Legal Business Name): SPECTRUM HEALTH WORTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2010
Last Update Date: 07/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4130 KALAMAZOO AVE SE MAIL CODE 017
GRAND RAPIDS MI
49508-3605
US

IV. Provider business mailing address

750 FULLER AVE NE MAIL CODE 133
GRAND RAPIDS MI
49503-1918
US

V. Phone/Fax

Practice location:
  • Phone: 616-455-7300
  • Fax:
Mailing address:
  • Phone: 616-455-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. LAWRENCE J OBERST
Title or Position: SHCC/DIRECTOR OF FINANCE
Credential: CPA
Phone: 616-486-2405