Basic Information
| Provider Information | |||||||||
| NPI: | 1376212357 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | DEREK | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 KENMOOR AVE SE STE 100 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495462395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163565000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 601 MICHIGAN AVE STE 220 | ||||||||
| Address2: | |||||||||
| City: | HOLLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494234951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163554284 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2021 | ||||||||
| LastUpdateDate: | 09/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501020221 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.