Provider Demographics
NPI:1689064610
Name:GRAND VALLEY STATE UNIVERSITY
Entity Type:Organization
Organization Name:GRAND VALLEY STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE PROFESSOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HATZEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-331-8538
Mailing Address - Street 1:4932 W CAMPUS DR
Mailing Address - Street 2:UNIT B14
Mailing Address - City:ALLENDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49401-8822
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:ALLENDALE
Practice Address - State:MI
Practice Address - Zip Code:49401-9401
Practice Address - Country:US
Practice Address - Phone:616-331-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-29
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty