Provider Demographics
NPI:1295243228
Name:BLUMKE, ZACHARY
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:BLUMKE
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 1:1490 E BELTLINE AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-4336
Mailing Address - Country:US
Mailing Address - Phone:616-940-0040
Mailing Address - Fax:
Practice Address - Street 1:41521 W 11 MILE RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-1803
Practice Address - Country:US
Practice Address - Phone:248-299-0030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2018-12-27
Deactivation Date:2018-07-03
Deactivation Code:
Reactivation Date:2018-12-05
Provider Licenses
StateLicense IDTaxonomies
MI12952432283747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant