=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710071360
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LINK A DEPHOUSE PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2006
-----------------------------------------------------
Last Update Date | 01/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 921 SOUTH BEECHTREE STREET SUITE 5
-----------------------------------------------------
City | GRAND HAVEN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49417-2385
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-842-0555
-----------------------------------------------------
Fax | 616-842-0553
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18000 COVE STREET SUITE 202
-----------------------------------------------------
City | SPRING LAKE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49456-1383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-847-1280
-----------------------------------------------------
Fax | 616-847-1290
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 5501011546
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------