Facts
- Status
- A
- Type
- Individual
- Enumeration date
- 2017-08-16
- Last updated
- 2018-10-24
Specialties
Licenses
- License MI
- 6801102238
Location
- Practice location
- 1049 E NEWELL ST
- City
- WHITE CLOUD MI
- Postal code
- 493498795
- Phone
- 231-689-7330
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.