Healthcare Provider Details

I. General information

NPI: 1568313005
Provider Name (Legal Business Name): CONARD DEVERL REYBURN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2026
Last Update Date: 02/09/2026
Certification Date: 02/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17615 E MOORE RD
GRANT MI
49327
US

IV. Provider business mailing address

17615 E MOORE RD
GRANT MI
49327
US

V. Phone/Fax

Practice location:
  • Phone: 231-834-0208
  • Fax:
Mailing address:
  • Phone: 231-834-0208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502009002
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: