Provider Demographics
NPI:1386043719
Name:GRAND VALLEY STATE UNIVERSITY
Entity Type:Organization
Organization Name:GRAND VALLEY STATE UNIVERSITY
Other - Org Name:GRAND VALLEY STATE UNIVERSITY FAMILY HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:ASSISTANT DEAN FOR PRACTICE KCON
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEEHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, RN, CPNP
Authorized Official - Phone:616-988-8774
Mailing Address - Street 1:72 SHELDON BLVD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4234
Mailing Address - Country:US
Mailing Address - Phone:616-988-8774
Mailing Address - Fax:
Practice Address - Street 1:72 SHELDON BLVD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4234
Practice Address - Country:US
Practice Address - Phone:616-988-8774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704248959261Q00000X, 261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center