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General NPI Number Information
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NPI Number | 1124605910
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Entity Type | Organization
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Legal Business Name | GRAND RIVER SURGERY CENTER, LLC
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Dates
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Enumeration Date | 03/26/2021
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Last Update Date | 12/08/2021
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Provider Practice Location Address
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Address Line | 1090 TROWBRIDGE RD STE A
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City | EAST LANSING
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State | MI
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Zip | 48823-5220
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Country | US
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Telephone | 517-220-0240
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Fax | 517-200-4455
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Provider Business Mailing Address
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Address Line | 1090 TROWBRIDGE RD STE A
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City | EAST LANSING
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State | MI
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Zip | 48823-5220
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Country | US
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Telephone | 517-282-0851
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. DOUGLAS DIETZEL
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Credential | DO
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Telephone | 517-488-8800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number |
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License Number State |
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