Provider Demographics
NPI:1659710150
Name:VAN HARKEN, CARLI EDWARDS
Entity Type:Individual
Prefix:
First Name:CARLI
Middle Name:EDWARDS
Last Name:VAN HARKEN
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 1:300 S. STATE ST., STE 1
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464
Mailing Address - Country:US
Mailing Address - Phone:616-772-1986
Mailing Address - Fax:616-772-1844
Practice Address - Street 1:300 S. STATE ST.
Practice Address - Street 2:STE. 1
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464
Practice Address - Country:US
Practice Address - Phone:616-772-1986
Practice Address - Fax:616-772-1844
Is Sole Proprietor?:No
Enumeration Date:2013-06-18
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3501003271174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist