MEDICARE: KMI TECHNOLOGIES, PC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	163W00000X	Registered Nurse
2	163WP0808X	Psychiatric/Mental Health Registered Nurse
3	207QA0505X	Adult Medicine Physician
4	2084P0800X	Psychiatry Physician
5	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1154205755
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KMI TECHNOLOGIES, PC

Provider Business Mailing Address
First Line	:	2815 MICHIGAN ST NE STE D
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49506-1266
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2815 MICHIGAN ST NE STE D
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49506-1266
Country	:	US
Telephone Number	:	435-680-9782
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	MR. CHARLES DECOSTER
Credential	:
Telephone Number	:	435-680-9782

Provider Enumeration Date	:	08/05/2025
Last Update Date	:	08/26/2025

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