Healthcare Provider Details

I. General information

NPI: 1447647722
Provider Name (Legal Business Name): SHELBY HEYBOER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2015
Last Update Date: 04/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2786 56TH ST SW
WYOMING MI
49418-8708
US

IV. Provider business mailing address

614 146TH AVE
CALEDONIA MI
49316-9210
US

V. Phone/Fax

Practice location:
  • Phone: 616-261-3960
  • Fax:
Mailing address:
  • Phone: 616-514-2691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number5202002443
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: