Healthcare Provider Details

I. General information

NPI: 1811245921
Provider Name (Legal Business Name): RACHEL A SMALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2012
Last Update Date: 11/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6016 LOVERS LN SUITE 3
PORTAGE MI
49002-3050
US

IV. Provider business mailing address

607 DEWEY AVE NW SUITE 300
GRAND RAPIDS MI
49504-7335
US

V. Phone/Fax

Practice location:
  • Phone: 269-329-0934
  • Fax:
Mailing address:
  • Phone: 616-356-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501015963
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: