Provider Demographics
NPI:1649919309
Name:MACDONALD, EVAN (LMT)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:MACDONALD
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 PORT SHELDON ST
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428-9341
Mailing Address - Country:US
Mailing Address - Phone:616-610-1179
Mailing Address - Fax:
Practice Address - Street 1:1421 60TH ST SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-7065
Practice Address - Country:US
Practice Address - Phone:616-610-1179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501015035225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty