Healthcare Provider Details

I. General information

NPI: 1801909452
Provider Name (Legal Business Name): MARY F LUSTIG AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 04/24/2025
Certification Date: 04/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

399 E 32ND ST STE 70
HOLLAND MI
49423-5518
US

IV. Provider business mailing address

577 MICHIGAN AVE SUITE 101
HOLLAND MI
49423-4911
US

V. Phone/Fax

Practice location:
  • Phone: 616-392-2222
  • Fax: 616-499-7229
Mailing address:
  • Phone: 616-393-2190
  • Fax: 616-393-0147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number1601000125
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number1601000125
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: