Healthcare Provider Details

I. General information

NPI: 1003355892
Provider Name (Legal Business Name): RYAN STANKEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2017
Last Update Date: 02/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 WILSON AVE NW
GRAND RAPIDS MI
49534-3554
US

IV. Provider business mailing address

6725 HOMERICH AVE SW
BYRON CENTER MI
49315-8730
US

V. Phone/Fax

Practice location:
  • Phone: 616-735-2110
  • Fax:
Mailing address:
  • Phone: 616-550-8757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number5302041981
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: