Healthcare Provider Details

I. General information

NPI: 1477082931
Provider Name (Legal Business Name): RYAN JOSEPH YOON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2017
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17325 VAN WAGONER RD
SPRING LAKE MI
49456-9702
US

IV. Provider business mailing address

300 68TH STREET SE PINE REST CHRISTIAN MENTAL HEALTH SERVICES
GRAND RAPIDS MI
49548
US

V. Phone/Fax

Practice location:
  • Phone: 616-847-5145
  • Fax:
Mailing address:
  • Phone: 616-456-0842
  • Fax: 616-559-5864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number5101023166
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number5151012555
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number5101026146
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: