Provider Demographics
NPI:1477515443
Name:VAN DE WALKER, RAY CHRISTIAN (DC)
Entity Type:Individual
Prefix:DR
First Name:RAY
Middle Name:CHRISTIAN
Last Name:VAN DE WALKER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1112 E CENTRE AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-5575
Mailing Address - Country:US
Mailing Address - Phone:269-978-3000
Mailing Address - Fax:269-978-3001
Practice Address - Street 1:1112 E CENTRE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-5575
Practice Address - Country:US
Practice Address - Phone:269-978-3000
Practice Address - Fax:269-978-3001
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008479111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950C95062OtherBLUE CROSS
MIU87552Medicare UPIN
MI950C95062OtherBLUE CROSS