Provider Demographics
NPI:1679671903
Name:SPECTRUM HEALTH - KENT COMMUNITY CAMPUS
Entity Type:Organization
Organization Name:SPECTRUM HEALTH - KENT COMMUNITY CAMPUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO SPECTRUM HEALTH CONTINUING CARE
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-486-2405
Mailing Address - Street 1:750 FULLER AVE NE MC 160
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1918
Mailing Address - Country:US
Mailing Address - Phone:616-643-9083
Mailing Address - Fax:616-643-9060
Practice Address - Street 1:750 FULLER AVE NE MC 160
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1918
Practice Address - Country:US
Practice Address - Phone:616-643-9083
Practice Address - Fax:616-643-9060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4162210001Medicare ID - Type Unspecified