Healthcare Provider Details

I. General information

NPI: 1841892437
Provider Name (Legal Business Name): HUNTER LYNN GANTOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2020
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 KALAMAZOO ST
EAST LANSING MI
48824-5400
US

IV. Provider business mailing address

15 CAVAILLON
NEWPORT COAST CA
92657-0133
US

V. Phone/Fax

Practice location:
  • Phone: 517-355-1610
  • Fax:
Mailing address:
  • Phone:
  • 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: