Provider Demographics
NPI:1821465956
Name:GRAND WELLNESS, LLC
Entity Type:Organization
Organization Name:GRAND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:MS
Authorized Official - First Name:VIKKI
Authorized Official - Middle Name:
Authorized Official - Last Name:NESTICO
Authorized Official - Suffix:
Authorized Official - Credentials:L AC
Authorized Official - Phone:917-376-4001
Mailing Address - Street 1:1531 LAKE GROVE AVE SE
Mailing Address - Street 2:
Mailing Address - City:EAST GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-4741
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:751 KENMOOR AVE SE STE H
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2391
Practice Address - Country:US
Practice Address - Phone:616-466-4175
Practice Address - Fax:616-259-4855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-24
Last Update Date:2021-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5401000137171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty