Basic Information
Provider Information | |||||||||
NPI: | 1952584070 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WEST MICHIGAN FAMILY FOOTCARE PLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | STEPHEN D HARRIS | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 8129 | ||||||||
Address2: |   | ||||||||
City: | KENTWOOD | ||||||||
State: | MI | ||||||||
PostalCode: | 495188129 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8003789991 | ||||||||
FaxNumber: | 6169498540 | ||||||||
Practice Location | |||||||||
Address1: | 4635 44TH ST SE | ||||||||
Address2: | SUITE C150 | ||||||||
City: | KENTWOOD | ||||||||
State: | MI | ||||||||
PostalCode: | 495124127 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8003789991 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/12/2007 | ||||||||
LastUpdateDate: | 04/19/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WILLIAMS | ||||||||
AuthorizedOfficialFirstName: | DEBRA | ||||||||
AuthorizedOfficialMiddleName: | K | ||||||||
AuthorizedOfficialTitleorPosition: | SUPERVISOR | ||||||||
AuthorizedOfficialTelephone: | 8003789991 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 5901001348 | MI | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
No ID Information.