MEDICARE: MATTHEW THAYER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	F	MI

General Provider Information

NPI Number	:	1093885329
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MATTHEW THAYER

Provider Business Mailing Address
First Line	:	3305 REMEMBRANCE RD NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49534-7729
Country	:	US
Telephone Number	:	616-826-6231
Fax Number	:	616-791-4060

Provider Business Practice Location Address
First Line	:	3305 REMEMBRANCE RD NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49534-7729
Country	:	US
Telephone Number	:	616-826-6231
Fax Number	:	616-791-4060

Authorized Official
Title or Position	:	OWNER
Name	:	MR. MATTHEW THAYER
Credential	:
Telephone Number	:	616-826-6231

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	07/21/2022

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