Provider Demographics
NPI:1053074401
Name:MACATAWA WELLNESS LLC
Entity type:Organization
Organization Name:MACATAWA WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEROO
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:616-886-4440
Mailing Address - Street 1:4799 WILDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7356
Mailing Address - Country:US
Mailing Address - Phone:616-836-5153
Mailing Address - Fax:
Practice Address - Street 1:35 1/2 W 8TH ST STE 4
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3158
Practice Address - Country:US
Practice Address - Phone:616-886-4440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-21
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health