Provider Demographics
NPI:1689646846
Name:GRAND RIVER HEALTH CENTER, PLC
Entity Type:Organization
Organization Name:GRAND RIVER HEALTH CENTER, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:TREECE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:734-266-2780
Mailing Address - Street 1:19460 GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-1200
Mailing Address - Country:US
Mailing Address - Phone:313-387-1097
Mailing Address - Fax:313-387-8795
Practice Address - Street 1:19460 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-1200
Practice Address - Country:US
Practice Address - Phone:313-387-1097
Practice Address - Fax:313-387-8795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0N63770Medicare PIN