Healthcare Provider Details

I. General information

NPI: 1912480583
Provider Name (Legal Business Name): DANIEL EVAN WESTRATE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2018
Last Update Date: 09/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CHERRY ST SE
GRAND RAPIDS MI
49503-4526
US

IV. Provider business mailing address

2202 KENOWA AVE SW
GRAND RAPIDS MI
49534-6535
US

V. Phone/Fax

Practice location:
  • Phone: 616-965-8278
  • Fax:
Mailing address:
  • Phone: 231-638-3234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number5302043702
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: