Basic Information
| Provider Information | |||||||||
| NPI: | 1114065950 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEVRIES | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2120 43RD ST SE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495083772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162811144 | ||||||||
| FaxNumber: | 6164568208 | ||||||||
| Practice Location | |||||||||
| Address1: | 2185 84TH ST SW | ||||||||
| Address2: | SUITE H | ||||||||
| City: | BYRON CENTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493158021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162492924 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 11/09/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501010006 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 5501010006 | 01 | MI | LICENSE | OTHER |