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General NPI Number Information
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NPI Number | 1366956583
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Entity Type | Organization
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Legal Business Name | MALIBU GROUP LLC
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Dates
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Enumeration Date | 11/27/2017
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Last Update Date | 11/27/2017
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Provider Practice Location Address
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Address Line | 5258 PLAINFIELD AVE NE
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City | GRAND RAPIDS
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State | MI
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Zip | 49525-1092
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Country | US
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Telephone | 616-635-2398
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Fax |
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Provider Business Mailing Address
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Address Line | 4075 YARROW DR NE
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City | GRAND RAPIDS
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State | MI
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Zip | 49525-9531
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | CORINN NICHOLS
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Credential |
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Telephone | 616-450-4125
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 247200000X
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Taxonomy Name | Other Technician
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License Number |
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License Number State |
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