Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251N0400X | Physical Therapist - Neurology |
NPI | 1487211025 |
---|---|
Provider Name | Samuel Vanderwoude |
First Address | Grand Rapids, MI 49506-1712 |
Second Address | Grand Rapids, MI 49506-4336 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/05/2019 |
Last Update Date | 20/05/2019 |