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General NPI Number Information
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NPI Number | 1538774849
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Entity Type | Individual
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Provider Name | GRACE MIERENDORF LAT, ATC
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Gender | Female
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Dates
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Enumeration Date | 09/14/2020
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Last Update Date | 11/08/2024
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Provider Practice Location Address
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Address Line | 2770 E BELTLINE AVE NE
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City | GRAND RAPIDS
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State | MI
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Zip | 49525-8614
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Country | US
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Telephone | 616-267-7000
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Fax |
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Provider Business Mailing Address
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Address Line | 820 MEADOW DR
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City | WAYLAND
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State | MI
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Zip | 49348-1369
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Country | US
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Telephone | 269-680-9159
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2601002645
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License Number State | MI
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