Provider Demographics
NPI:1003126400
Name:FS GRAND RAPIDS SOUTH, LLC
Entity Type:Organization
Organization Name:FS GRAND RAPIDS SOUTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:SKINNER
Authorized Official - Suffix:JR
Authorized Official - Credentials:C PED
Authorized Official - Phone:616-698-7200
Mailing Address - Street 1:6750 KALAMAZOO AVE SE
Mailing Address - Street 2:SUITE E
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-7897
Mailing Address - Country:US
Mailing Address - Phone:616-698-7200
Mailing Address - Fax:616-698-7212
Practice Address - Street 1:6750 KALAMAZOO AVE SE
Practice Address - Street 2:SUITE E
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-7897
Practice Address - Country:US
Practice Address - Phone:616-698-7200
Practice Address - Fax:616-698-7212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-19
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICPED3413335E00000X
MICPED3429335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier