MEDICARE: XIAOFENG S BOTNER

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	390200000X	Student in an Organized Health Care Education/Training Program	5302042712	MI

General Provider Information

NPI Number	:	1962936831
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	XIAOFENG S BOTNER

Provider Business Mailing Address
First Line	:	1104 STONEBROOK CT NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49505-7216
Country	:	US
Telephone Number	:	734-649-9096
Fax Number	:

Provider Business Practice Location Address
First Line	:	1104 STONEBROOK CT NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49505-7216
Country	:	US
Telephone Number	:	734-649-9096
Fax Number	:

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

Provider Enumeration Date	:	04/17/2017
Last Update Date	:	04/17/2017

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Directions to “ XIAOFENG S BOTNER ” Practice Location

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