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General NPI Number Information
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NPI Number | 1649160375
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Entity Type | Organization
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Legal Business Name | LSD CENTER OF EXCELLENCE LLC
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Dates
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Enumeration Date | 07/04/2025
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Last Update Date | 07/04/2025
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Provider Practice Location Address
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Address Line | 200 WOODLAND PASS STE D
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City | EAST LANSING
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State | MI
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Zip | 48823-2000
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Country | US
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Telephone | 616-540-9365
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Fax |
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Provider Business Mailing Address
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Address Line | 3024 BONITA DR SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49508-1424
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Country | US
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Telephone | 616-540-9365
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Fax |
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | MRS. KIMBERLY S AGIM
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Credential | ANP-BC
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Telephone | 616-540-9365
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207SG0201X
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Taxonomy Name | Clinical Genetics (M.D.) Physician
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License Number |
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License Number State |
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