Provider Demographics
NPI:1841541307
Name:SPECTRUM HEALTH SLEEP DISORDERS CENTER
Entity type:Organization
Organization Name:SPECTRUM HEALTH SLEEP DISORDERS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CARE MANAGEMENT COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DE METRIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:RPSGT
Authorized Official - Phone:616-391-3759
Mailing Address - Street 1:4100 LAKE DR SE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8292
Mailing Address - Country:US
Mailing Address - Phone:616-391-3759
Mailing Address - Fax:616-267-8232
Practice Address - Street 1:4100 LAKE DR SE
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8292
Practice Address - Country:US
Practice Address - Phone:616-391-3759
Practice Address - Fax:616-267-8232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI15206246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Single Specialty