Provider Demographics
NPI:1003353640
Name:HOLLAND FOOT AND ANKLE CENTER, PC
Entity Type:Organization
Organization Name:HOLLAND FOOT AND ANKLE CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN TIL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:616-392-7472
Mailing Address - Street 1:904 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7724
Mailing Address - Country:US
Mailing Address - Phone:616-392-7472
Mailing Address - Fax:616-392-3327
Practice Address - Street 1:551 LINN ST
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-1595
Practice Address - Country:US
Practice Address - Phone:616-392-7472
Practice Address - Fax:616-392-3327
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOLLAND FOOT AND ANKLE CENTER, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-20
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI213E00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0406640001Medicare NSC