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NPI Code Detail

MEDICARE: MICHAEL C. GULENCHYN LAT

MEDICARE: MICHAEL C. GULENCHYN LAT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12255A2300XAthletic Trainer114-039WI

General Provider Information

NPI Number : 1164404810
Entity Type Code : Individual
Provider Name (Legal Business Name) : MICHAEL C. GULENCHYN LAT
Provider Business Mailing Address
First Line : 1000 N OAK AVE
Second Line :
City : MARSHFIELD
State : WI
Zip : 54449-5703
Country : US
Telephone Number : 715-387-5511
Fax Number :
Provider Business Practice Location Address
First Line : 410 DEWEY ST
Second Line :
City : WISCONSIN RAPIDS
State : WI
Zip : 54495-8075
Country : US
Telephone Number : 715-421-5257
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/17/2005
Last Update Date : 02/01/2012

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