MEDICARE: SPECTRUM HEALTH WORTH SERVICES

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	320700000X	Physical Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1164734364
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPECTRUM HEALTH WORTH SERVICES

Provider Business Mailing Address
First Line	:	750 FULLER AVE NE
Second Line	:	MAIL CODE 133
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-1918
Country	:	US
Telephone Number	:	616-455-7300
Fax Number	:

Provider Business Practice Location Address
First Line	:	4130 KALAMAZOO AVE SE
Second Line	:	MAIL CODE 017
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-3605
Country	:	US
Telephone Number	:	616-455-7300
Fax Number	:

Authorized Official
Title or Position	:	SHCC/DIRECTOR OF FINANCE
Name	:	MR. LAWRENCE J OBERST
Credential	:	CPA
Telephone Number	:	616-486-2405

Provider Enumeration Date	:	07/06/2010
Last Update Date	:	07/06/2010

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