Healthcare Provider Details

I. General information

NPI: 1033650916
Provider Name (Legal Business Name): MEAZAG GEBREAMLAK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2017
Last Update Date: 03/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 COUNTRY CLUB DR
GRAND RAPIDS MI
49505
US

IV. Provider business mailing address

1701 COUNTRY CLUB DR NE
GRAND RAPIDS MI
49505-4808
US

V. Phone/Fax

Practice location:
  • Phone: 616-560-6364
  • Fax:
Mailing address:
  • Phone: 616-560-6364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: