Healthcare Provider Details

I. General information

NPI: 1437378270
Provider Name (Legal Business Name): ERIC THOMAS BROEKHUIZEN ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 FRANK LLOYD WRIGHT DR
ANN ARBOR MI
48105-9755
US

IV. Provider business mailing address

623 BERKSHIRE DR
SALINE MI
48176-1069
US

V. Phone/Fax

Practice location:
  • Phone: 734-930-7400
  • Fax:
Mailing address:
  • Phone: 734-316-2288
  • 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: