Healthcare Provider Details

I. General information

NPI: 1114553856
Provider Name (Legal Business Name): DANTE N/A BERMEJO RONQUILLO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2020
Last Update Date: 03/13/2020
Certification Date: 03/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3492 LAKE DR SE
GRAND RAPIDS MI
49546-4338
US

IV. Provider business mailing address

3492 LAKE DR SE
GRAND RAPIDS MI
49546-4338
US

V. Phone/Fax

Practice location:
  • Phone: 855-407-7575
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: