Healthcare Provider Details

I. General information

NPI: 1679161020
Provider Name (Legal Business Name): SAMUEL CORBIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2020
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 6 MILE RD NE
COMSTOCK PARK MI
49321-8022
US

IV. Provider business mailing address

101 SCHOOL ST, COMSTOCK PARK, MICHIGAN
COMSTOCK PARK MI
49321
US

V. Phone/Fax

Practice location:
  • Phone: 616-254-5236
  • Fax:
Mailing address:
  • Phone: 616-254-5236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601003003
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: