Healthcare Provider Details

I. General information

NPI: 1578490603
Provider Name (Legal Business Name): SAMIRA LAWRENCE CCPS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 W SOUTH ST
KALAMAZOO MI
49007-4710
US

IV. Provider business mailing address

126 E KILGORE RD STE 400
PORTAGE MI
49002-0596
US

V. Phone/Fax

Practice location:
  • Phone: 404-219-9717
  • Fax:
Mailing address:
  • Phone: 404-219-9717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: