Provider Demographics
NPI:1750400172
Name:FAN, WIN-CHI (DC)
Entity type:Individual
Prefix:DR
First Name:WIN-CHI
Middle Name:
Last Name:FAN
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 1:5429 NORTHLAND DR NE
Mailing Address - Street 2:SUITE B
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-1089
Mailing Address - Country:US
Mailing Address - Phone:616-361-8881
Mailing Address - Fax:
Practice Address - Street 1:5429 NORTHLAND DR NE
Practice Address - Street 2:SUITE B
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-1089
Practice Address - Country:US
Practice Address - Phone:616-361-8881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007776111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3835209930OtherBCBS COMMERCIAL
MI0N10470Medicare ID - Type UnspecifiedMEDICARE #
MI3835209930OtherBCBS COMMERCIAL