Healthcare Provider Details

I. General information

NPI: 1932952504
Provider Name (Legal Business Name): PEDRO IRIZARRY PLAZA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2024
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 W CENTRE AVE
PORTAGE MI
49024-4828
US

IV. Provider business mailing address

2600 W CENTRE AVE
PORTAGE MI
49024-4828
US

V. Phone/Fax

Practice location:
  • Phone: 269-324-4141
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number4704364517
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: