Basic Information
| Provider Information | |||||||||
| NPI: | 1154505337 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEDGWOOD CHRISTIAN SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 36TH ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495122810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169422110 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3300 36TH ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495122810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169422110 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/24/2007 | ||||||||
| LastUpdateDate: | 12/24/2007 | ||||||||
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| AuthorizedOfficialLastName: | BEALS | ||||||||
| AuthorizedOfficialFirstName: | SAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6169422110 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | L1118706 | MI | Y | Agencies | Community/Behavioral Health |
No ID Information.