Provider Demographics
NPI:1609129782
Name:DEBOSE, RONALD
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:
Last Name:DEBOSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1427 BALL AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-5613
Mailing Address - Country:US
Mailing Address - Phone:616-459-6817
Mailing Address - Fax:616-459-1930
Practice Address - Street 1:1139 THOMAS ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2665
Practice Address - Country:US
Practice Address - Phone:616-459-6817
Practice Address - Fax:616-459-1930
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility