=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922735612
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PENGUIN PEDIATRIC THERAPIES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2022
-----------------------------------------------------
Last Update Date | 08/03/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 COLLEGE AVE SE STE 203
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49503-5945
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-256-0016
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6907 RIX ST SE
-----------------------------------------------------
City | ADA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49301-9030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-256-0016
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | HEATHER FRANCIS
-----------------------------------------------------
Credential | MA, CCC-SLP
-----------------------------------------------------
Telephone | 616-401-9098
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------