Provider Demographics
NPI:1679824361
Name:HAVENS, MICHAEL E (RD, LD, CNSC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:E
Last Name:HAVENS
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Gender:M
Credentials:RD, LD, CNSC
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Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MAIL CODE 845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-486-6790
Mailing Address - Fax:616-486-6702
Practice Address - Street 1:212 S SULLIVAN AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-1548
Practice Address - Country:US
Practice Address - Phone:616-391-3139
Practice Address - Fax:616-391-3044
Is Sole Proprietor?:No
Enumeration Date:2012-09-21
Last Update Date:2016-06-03
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Provider Licenses
StateLicense IDTaxonomies
MI5601007732363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant