MEDICARE: GREG ALLEN BOOTH VANDER WEL LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	4703114773	MI

General Provider Information

NPI Number	:	1023680964
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREG ALLEN BOOTH VANDER WEL LPN

Provider Business Mailing Address
First Line	:	470 BALTIMORE DR NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-3934
Country	:	US
Telephone Number	:	616-726-1909
Fax Number	:

Provider Business Practice Location Address
First Line	:	470 BALTIMORE DR NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-3934
Country	:	US
Telephone Number	:	616-726-1909
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2021
Last Update Date	:	07/12/2021

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