Healthcare Provider Details

I. General information

NPI: 1558963736
Provider Name (Legal Business Name): ALEXIS CLAIRE GANOP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2020
Last Update Date: 11/12/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1490 E BELTLINE AVE SE
GRAND RAPIDS MI
49506-4336
US

IV. Provider business mailing address

2900 SWANSEA DR SE
GRAND RAPIDS MI
49546-5672
US

V. Phone/Fax

Practice location:
  • Phone: 855-407-7575
  • Fax: 616-940-8151
Mailing address:
  • Phone: 734-365-1512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: