Provider Demographics
NPI:1699012104
Name:RELUCIO, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:RELUCIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 CHARLEVOIX DR SE
Mailing Address - Street 2:STE. 200
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7085
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2900 CHARLEVOIX DR SE
Practice Address - Street 2:STE. 200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-7085
Practice Address - Country:US
Practice Address - Phone:866-588-4299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-04
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT 9024225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant