Provider Demographics
NPI:1407535313
Name:VANAKEN, TREY D
Entity Type:Individual
Prefix:
First Name:TREY
Middle Name:D
Last Name:VANAKEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 RIVERFRONT DR APT 206
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-4535
Mailing Address - Country:US
Mailing Address - Phone:517-262-5142
Mailing Address - Fax:
Practice Address - Street 1:540 E CANFIELD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1928
Practice Address - Country:US
Practice Address - Phone:313-577-1466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health