Provider Demographics
NPI:1558377192
Name:WEST MICHIGAN CENTER FOR FAMILY
Entity Type:Organization
Organization Name:WEST MICHIGAN CENTER FOR FAMILY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLTINGHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-233-0933
Mailing Address - Street 1:1425 MICHIGAN ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2027
Mailing Address - Country:US
Mailing Address - Phone:616-233-0933
Mailing Address - Fax:
Practice Address - Street 1:1425 MICHIGAN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2027
Practice Address - Country:US
Practice Address - Phone:616-233-0933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009309207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N88510Medicare ID - Type Unspecified