1922415876 NPI number — MRS. CHELSEA DIANE BRUINSMA MA

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 1922415876 NPI number — MRS. CHELSEA DIANE BRUINSMA MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUINSMA
Provider First Name:
CHELSEA
Provider Middle Name:
DIANE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BLACKMORE
Provider Other First Name:
CHELSEA
Provider Other Middle Name:
DIANE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1922415876
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11877 RITCHIE AVE NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CEDAR SPRINGS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49319-9400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-560-2987
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1305 WALKER AVE NW
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:
49504-4098
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-419-3095
Provider Business Practice Location Address Fax Number:
616-419-3147
Provider Enumeration Date:
07/11/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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