Basic Information
| Provider Information | |||||||||
| NPI: | 1851309884 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PINE REST CHRISTIAN MENTAL HEALTH SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 68TH ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495486927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164555000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 68TH ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495486927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164555000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| AuthorizedOfficialLastName: | FENNEMA | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGED CARE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6162816372 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PINE REST CHRISTIAN MENTAL HEALTH SERVICES | ||||||||
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| NPICertificationDate: | 11/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.