Healthcare Provider Details

I. General information

NPI: 1295348092
Provider Name (Legal Business Name): MICHAEL ALLEN VANEERDEN LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2020
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1359 EMERALD AVE NE
GRAND RAPIDS MI
49505-5226
US

IV. Provider business mailing address

1359 EMERALD AVE NE
GRAND RAPIDS MI
49505-5226
US

V. Phone/Fax

Practice location:
  • Phone: 574-612-4458
  • Fax:
Mailing address:
  • Phone: 574-612-4458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7501009828
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: