Basic Information
| Provider Information | |||||||||
| NPI: | 1912480583 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WESTRATE | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | EVAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2202 KENOWA AVE SW | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495346535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316383234 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 CHERRY ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169658278 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2018 | ||||||||
| LastUpdateDate: | 09/10/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 5302043702 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.