Healthcare Provider Details

I. General information

NPI: 1689713844
Provider Name (Legal Business Name): WEST MICHIGAN PEDORTHICS MEDICAL SUPPLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 06/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3324 GLADE ST
MUSKEGON MI
49444-2708
US

IV. Provider business mailing address

3324 GLADE ST
MUSKEGON MI
49444-2708
US

V. Phone/Fax

Practice location:
  • Phone: 231-739-4414
  • Fax: 231-739-1094
Mailing address:
  • Phone: 231-739-4414
  • Fax: 231-739-1094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN ROBERT YARRANTON
Title or Position: CEO
Credential: PEDORTHIST ORTHOTIST
Phone: 231-739-4414