Basic Information
| Provider Information | |||||||||
| NPI: | 1124390505 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPECTRUM HEALTH UNITED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MICHIGAN ST NE | ||||||||
| Address2: | MC 845 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495032560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164866790 | ||||||||
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| Practice Location | |||||||||
| Address1: | 701 S GREENVILLE WEST DR | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488383516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167546185 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2012 | ||||||||
| LastUpdateDate: | 12/26/2013 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | RYAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6162256310 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SPECTRUM HEALTH UNITED | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 251B00000X | Y | Agencies | Case Management |
No ID Information.