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General NPI Number Information
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NPI Number | 1053570499
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Entity Type | Organization
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Legal Business Name | MED1
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Dates
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Enumeration Date | 06/02/2008
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Last Update Date | 06/02/2008
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Provider Practice Location Address
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Address Line | 1140 MONROE AVE NW SUITE 150
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City | GRAND RAPIDS
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State | MI
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Zip | 49503-1055
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Country | US
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Telephone | 616-459-6331
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Fax |
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Provider Business Mailing Address
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Address Line | 1140 MONROE AVE NW SUITE 150
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City | GRAND RAPIDS
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State | MI
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Zip | 49503-1055
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Country | US
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Telephone | 616-459-6331
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE VICE PRESIDENT
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Name | MRS. MARY ALICE EHRLICH
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Credential | RN,BSN,MS
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Telephone | 616-459-6331
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 5501011266
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License Number State | MI
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