Provider Demographics
NPI:1265771448
Name:GRAND RAPIDS PAIN FREE CLINIC INC
Entity type:Organization
Organization Name:GRAND RAPIDS PAIN FREE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:RADOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-458-8063
Mailing Address - Street 1:831 FULLER AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1901
Mailing Address - Country:US
Mailing Address - Phone:616-458-8063
Mailing Address - Fax:616-458-6711
Practice Address - Street 1:831 FULLER AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1901
Practice Address - Country:US
Practice Address - Phone:616-458-8063
Practice Address - Fax:616-458-6711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-07
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty