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General NPI Number Information
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NPI Number | 1497618706
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Entity Type | Organization
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Legal Business Name | GODSCHILD77 LLC
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Dates
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Enumeration Date | 12/04/2025
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Last Update Date | 12/04/2025
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Provider Practice Location Address
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Address Line | 1690 WATERTOWER PL STE 100-214
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City | EAST LANSING
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State | MI
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Zip | 48823-8046
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Country | US
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Telephone | 517-442-8709
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Fax |
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Provider Business Mailing Address
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Address Line | 5235 CROCUS AVE
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City | LANSING
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State | MI
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Zip | 48911-3734
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Country | US
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Telephone | 517-442-8709
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Fax |
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Authorized Official
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Title or Position | CEO/OWNER
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Name | DIANE MARIE DEWEY
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Credential | CLIA WAIVED CERT.
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Telephone | 517-442-8708
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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