Provider Demographics
NPI:1679535512
Name:SANDERS, RAYMOND DEXTER (DC)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:DEXTER
Last Name:SANDERS
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 1:635 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-1237
Mailing Address - Country:US
Mailing Address - Phone:616-842-9411
Mailing Address - Fax:616-842-9058
Practice Address - Street 1:635 FULTON ST
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-1237
Practice Address - Country:US
Practice Address - Phone:616-842-9411
Practice Address - Fax:616-842-9058
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRS008001111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIX24786Medicare UPIN
MIU90447Medicare UPIN