Healthcare Provider Details

I. General information

NPI: 1952685752
Provider Name (Legal Business Name): RYAN DAVID MEHMANDOOST-GAUTHIER LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: RYAN GAUTHIER

II. Dates (important events)

Enumeration Date: 09/29/2011
Last Update Date: 09/10/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 AUTO CLUB DR
DEARBORN MI
48126-2779
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 313-425-4545
  • Fax:
Mailing address:
  • Phone: 313-874-4806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC156213
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number5402000167
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: