Healthcare Provider Details

I. General information

NPI: 1487171872
Provider Name (Legal Business Name): BENJAMIN MARK MASTBERGEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2017
Last Update Date: 07/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5570 WILSON AVE SW STE A
WYOMING MI
49418-8867
US

IV. Provider business mailing address

4761 LAKE MICHIGAN DR NW STE A
GRAND RAPIDS MI
49534-6300
US

V. Phone/Fax

Practice location:
  • Phone: 616-855-1495
  • Fax: 616-855-1496
Mailing address:
  • Phone: 616-608-9978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501018373
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: