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Organization
PINE REST CHRISTIAN MENTAL HEALTH SERVICES
Active
Organization
PINE REST CHRISTIAN MENTAL HEALTH SERVICES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DIANE FENNEMA (MANAGED CARE ADMINISTRATOR)
(616) 281-6372
Entity
Organization
Contact information
Practice address
300 68TH ST SE, GRAND RAPIDS, MI 49548-6927
(616) 455-5000
Mailing address
300 68TH ST SE, GRAND RAPIDS, MI 49548-6927
(616) 455-5000
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0P08030
PHYSICIANS ASSISTANT
MI
Enumeration date
08/09/2006
Last updated
11/04/2020
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