Healthcare Provider Details

I. General information

NPI: 1124650262
Provider Name (Legal Business Name): KEVIN JOHN WALTERS LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2020
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3097 PRAIRIE ST SW
GRANDVILLE MI
49418-2000
US

IV. Provider business mailing address

3097 PRAIRIE ST SW
GRANDVILLE MI
49418-2000
US

V. Phone/Fax

Practice location:
  • Phone: 616-531-9973
  • Fax:
Mailing address:
  • Phone: 616-531-9973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number1649257734
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703079623
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: