1811965585 NPI number — KENT NEUROLOGICAL ASSOCIATES PC

Table of content: (NPI 1811965585)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811965585 NPI number — KENT NEUROLOGICAL ASSOCIATES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENT NEUROLOGICAL ASSOCIATES PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811965585
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3140
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49501-3140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-454-9246
Provider Business Mailing Address Fax Number:
616-970-6068

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3200 EAGLE PARK DR NE STE 108
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49525-7057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-454-9246
Provider Business Practice Location Address Fax Number:
616-970-6068
Provider Enumeration Date:
03/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
INES
Authorized Official First Name:
DESIDERIO
Authorized Official Middle Name:
FRANDA
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
616-454-9246

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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