Provider Demographics
NPI:1306062237
Name:GRAND VALLEY FAMILY HEALTH CENTER
Entity type:Organization
Organization Name:GRAND VALLEY FAMILY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:LEDERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-949-9944
Mailing Address - Street 1:2680 LEONARD ST NE STE 2
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-6902
Mailing Address - Country:US
Mailing Address - Phone:616-949-9944
Mailing Address - Fax:616-224-8687
Practice Address - Street 1:2680 LEONARD ST NE STE 2
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-949-2410
Practice Address - Fax:616-224-8687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D16139Medicare PIN