Healthcare Provider Details

I. General information

NPI: 1245577865
Provider Name (Legal Business Name): ALEICA L KOVATCH PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2013
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4055 CASCADE RD SE
GRAND RAPIDS MI
49546-2149
US

IV. Provider business mailing address

4055 CASCADE RD SE
GRAND RAPIDS MI
49546-2149
US

V. Phone/Fax

Practice location:
  • Phone: 616-252-5760
  • Fax:
Mailing address:
  • Phone: 616-252-5760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601006580
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: