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General NPI Number Information
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NPI Number | 1740718394
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Entity Type | Individual
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Provider Name | BRIAN RICHARD KOOIKER SR.
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Gender | Male
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Dates
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Enumeration Date | 05/26/2017
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Last Update Date | 05/26/2017
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Provider Practice Location Address
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Address Line | 6909 CANNONSBURG RD NE
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City | BELMONT
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State | MI
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Zip | 49306-9123
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Country | US
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Telephone | 616-745-6619
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Fax | 616-883-6736
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Provider Business Mailing Address
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Address Line | 6909 CANNONSBURG RD NE
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City | BELMONT
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State | MI
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Zip | 49306-9123
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Country | US
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Telephone | 616-745-6619
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Fax | 616-883-6736
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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 | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | AF410356288
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License Number State | MI
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