Healthcare Provider Details

I. General information

NPI: 1790472330
Provider Name (Legal Business Name): RYAN VOGEL AT, ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5060 CASCADE RD SE STE A
GRAND RAPIDS MI
49546-3808
US

IV. Provider business mailing address

7024 GARDENVIEW CT SW
BYRON CENTER MI
49315-8351
US

V. Phone/Fax

Practice location:
  • Phone: 616-954-0950
  • Fax:
Mailing address:
  • Phone: 269-908-3479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601001026
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: