Provider Demographics
NPI:1033650916
Name:GEBREAMLAK, MEAZAG
Entity Type:Individual
Prefix:
First Name:MEAZAG
Middle Name:
Last Name:GEBREAMLAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 COUNTRY CLUB DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-4808
Mailing Address - Country:US
Mailing Address - Phone:616-560-6364
Mailing Address - Fax:
Practice Address - Street 1:1701 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505
Practice Address - Country:US
Practice Address - Phone:616-560-6364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)