Healthcare Provider Details

I. General information

NPI: 1356653182
Provider Name (Legal Business Name): SPECTRUM HEALTH KELSEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2010
Last Update Date: 07/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 WASHINGTON ST
LAKEVIEW MI
48850-7102
US

IV. Provider business mailing address

100 MICHIGAN ST NE MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 989-352-6435
  • Fax: 989-352-8451
Mailing address:
  • Phone: 616-486-6790
  • Fax: 616-486-6702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. RYAN K JOHNSON
Title or Position: VP FINANCE
Credential:
Phone: 616-225-6428