Healthcare Provider Details

I. General information

NPI: 1932490885
Provider Name (Legal Business Name): PENNOCK STATE STREET CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2011
Last Update Date: 04/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 W STATE ST
HASTINGS MI
49058-9711
US

IV. Provider business mailing address

4100 EMBASSY DR SE SUITE 200
GRAND RAPIDS MI
49546-2416
US

V. Phone/Fax

Practice location:
  • Phone: 269-948-3360
  • Fax:
Mailing address:
  • Phone: 616-975-1845
  • Fax: 616-285-0846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: AMY POHOLSKI
Title or Position: DIRECTOR
Credential:
Phone: 616-975-1845