Provider Demographics
NPI:1649160375
Name:LSD CENTER OF EXCELLENCE LLC
Entity type:Organization
Organization Name:LSD CENTER OF EXCELLENCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:S
Authorized Official - Last Name:AGIM
Authorized Official - Suffix:
Authorized Official - Credentials:ANP-BC
Authorized Official - Phone:616-540-9365
Mailing Address - Street 1:3024 BONITA DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-1424
Mailing Address - Country:US
Mailing Address - Phone:616-540-9365
Mailing Address - Fax:
Practice Address - Street 1:200 WOODLAND PASS STE D
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-2000
Practice Address - Country:US
Practice Address - Phone:616-540-9365
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-04
Last Update Date:2025-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)Group - Single Specialty