MEDICARE: AMBER ROSE BRAUTIGAM

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	225400000X	Rehabilitation Practitioner

General Provider Information

NPI Number	:	1528595055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMBER ROSE BRAUTIGAM

Provider Business Mailing Address
First Line	:	315 FULLER AVE SE # 2
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49506-1639
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	315 FULLER AVE SE # 2
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49506-1639
Country	:	US
Telephone Number	:	231-360-5683
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2017
Last Update Date	:	05/15/2017

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Directions to “ AMBER ROSE BRAUTIGAM ” Practice Location

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