Provider Demographics
NPI:1013530369
Name:VERSALLE, RICHARD ALAN (BS)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:ALAN
Last Name:VERSALLE
Suffix:
Gender:M
Credentials:BS
Other - Prefix:MR
Other - First Name:RICK
Other - Middle Name:ALAN
Other - Last Name:VERSALLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:376 E APPLE AVE
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-3466
Mailing Address - Country:US
Mailing Address - Phone:231-288-2002
Mailing Address - Fax:231-724-3659
Practice Address - Street 1:376 E APPLE AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-3466
Practice Address - Country:US
Practice Address - Phone:231-724-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator