1881370799 NPI number — SHORELINE ORTHOPAEDIC & SPORTS MEDICINE CLINIC P L C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881370799 NPI number — SHORELINE ORTHOPAEDIC & SPORTS MEDICINE CLINIC P L C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHORELINE ORTHOPAEDIC & SPORTS MEDICINE CLINIC P L C
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:
1881370799
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
370 120TH AVE STE 20
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLAND
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49424-2196
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-396-5855
Provider Business Mailing Address Fax Number:
877-592-0688

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8251 WESTPARK WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ZEELAND
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49464
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-396-5855
Provider Business Practice Location Address Fax Number:
877-592-0688
Provider Enumeration Date:
06/26/2023

Additional Information

Authorized Official

Authorized Official Last Name:
SCHILDHOUSE
Authorized Official First Name:
TRICIA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
616-396-5855

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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