Healthcare Provider Details

I. General information

NPI: 1417266404
Provider Name (Legal Business Name): JUSTIN DALE REIMINK P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2010
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E PARIS AVE SE STE 200
GRAND RAPIDS MI
49546-8383
US

IV. Provider business mailing address

PO BOX 1847
MUSKEGON MI
49443-1847
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-3450
  • Fax: 616-685-3454
Mailing address:
  • Phone: 231-672-2119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601005884
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: