Healthcare Provider Details

I. General information

NPI: 1700625761
Provider Name (Legal Business Name): DR FRED PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2024
Last Update Date: 11/19/2025
Certification Date: 11/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 RAYBROOK ST SE STE 100B
GRAND RAPIDS MI
49546
US

IV. Provider business mailing address

743 E BELTLINE AVE NE
GRAND RAPIDS MI
49525-6045
US

V. Phone/Fax

Practice location:
  • Phone: 616-320-0096
  • Fax: 616-320-0097
Mailing address:
  • Phone: 616-320-0096
  • Fax: 616-320-0097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. FREDRIC REYELTS
Title or Position: PRESIDENT / CMO
Credential: MD
Phone: 616-320-0096