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General NPI Number Information
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NPI Number | 1558377192
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Entity Type | Organization
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Legal Business Name | WEST MICHIGAN CENTER FOR FAMILY
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Dates
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Enumeration Date | 08/01/2006
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Last Update Date | 03/18/2008
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Provider Practice Location Address
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Address Line | 1425 MICHIGAN ST NE
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City | GRAND RAPIDS
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State | MI
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Zip | 49503-2027
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Country | US
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Telephone | 616-233-0933
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Fax |
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Provider Business Mailing Address
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Address Line | 1425 MICHIGAN ST NE
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City | GRAND RAPIDS
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State | MI
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Zip | 49503-2027
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Country | US
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Telephone | 616-233-0933
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | BETH BOLTINGHOUSE
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Credential |
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Telephone | 616-233-0933
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 5101009309
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License Number State | MI
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