Healthcare Provider Details

I. General information

NPI: 1659741353
Provider Name (Legal Business Name): BRETT MARTIN KNOOP MED., AT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2015
Last Update Date: 10/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9050 KRAFT AVE SE
CALEDONIA MI
49316-7304
US

IV. Provider business mailing address

9050 KRAFT AVE SE
CALEDONIA MI
49316-7304
US

V. Phone/Fax

Practice location:
  • Phone: 616-891-8129
  • Fax: 616-891-7035
Mailing address:
  • Phone: 616-891-8129
  • Fax: 616-891-7035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601000385
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: