Healthcare Provider Details

I. General information

NPI: 1649816299
Provider Name (Legal Business Name): CONNOR PRYDE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2019
Last Update Date: 11/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1428 44TH ST SW
WYOMING MI
49509-4312
US

IV. Provider business mailing address

8067 VAN BUREN RD
FOWLERVILLE MI
48836-9010
US

V. Phone/Fax

Practice location:
  • Phone: 616-604-8492
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: