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General NPI Number Information
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NPI Number | 1235092131
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Entity Type | Individual
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Provider Name | JACK C METIVA
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Gender | Male
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Dates
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Enumeration Date | 12/08/2025
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Last Update Date | 12/08/2025
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Provider Practice Location Address
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Address Line | 6694 S M 88 HWY
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City | BELLAIRE
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State | MI
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Zip | 49615-9296
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Country | US
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Telephone | 616-481-1947
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Fax |
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Provider Business Mailing Address
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Address Line | 6694 S M 88 HWY
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City | BELLAIRE
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State | MI
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Zip | 49615-9296
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Country | US
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Telephone | 616-481-1947
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2279C0205X
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Taxonomy Name | Critical Care Registered Respiratory Therapist
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License Number | 95018
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License Number State | MI
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