Basic Information
| Provider Information | |||||||||
| NPI: | 1285830448 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROFESSIONAL FINANCIAL SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CLINICA SANTA MARIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 STATE ST SE | ||||||||
| Address2: | STE 1A | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166858050 | ||||||||
| FaxNumber: | 6166851850 | ||||||||
| Practice Location | |||||||||
| Address1: | 730 GRANDVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166858400 | ||||||||
| FaxNumber: | 6167421322 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2007 | ||||||||
| LastUpdateDate: | 07/09/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCORKLE | ||||||||
| AuthorizedOfficialFirstName: | PHILIP | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 6166851808 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TRINITY HEALTH - MICHIGAN | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.