Provider Demographics
NPI:1730561960
Name:WAN, RAYMOND (MAC, ADS, LMT,)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:WAN
Suffix:
Gender:M
Credentials:MAC, ADS, LMT,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3790 28TH ST SW
Mailing Address - Street 2:SUITE B
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1390
Mailing Address - Country:US
Mailing Address - Phone:616-419-6924
Mailing Address - Fax:
Practice Address - Street 1:3790 28TH ST SW
Practice Address - Street 2:SUITE B
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-1390
Practice Address - Country:US
Practice Address - Phone:616-419-6924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist