Healthcare Provider Details

I. General information

NPI: 1669446704
Provider Name (Legal Business Name): BRIAN MICHAEL HATZEL PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CAMPUS DRIVE, GRAND VALLEY STATE UNIVERSITY 184-B FIELDHOUSE
ALLENDALE MI
49401
US

IV. Provider business mailing address

13061 BLACKHAWK AVE
GRAND HAVEN MI
49417-8304
US

V. Phone/Fax

Practice location:
  • Phone: 616-331-8538
  • Fax:
Mailing address:
  • Phone: 616-293-1146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: