Provider Demographics
NPI:1588840854
Name:EXALTA HEALTH
Entity Type:Organization
Organization Name:EXALTA HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:PAXTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-475-1363
Mailing Address - Street 1:15 ANDRE ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-3010
Mailing Address - Country:US
Mailing Address - Phone:616-475-8420
Mailing Address - Fax:
Practice Address - Street 1:2060 DIVISION AVE S
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-3029
Practice Address - Country:US
Practice Address - Phone:616-475-8446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILV012688174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4355710Medicaid