Healthcare Provider Details

I. General information

NPI: 1720222003
Provider Name (Legal Business Name): JONATHAN DAVID LENZE ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2009
Last Update Date: 06/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 E COURT ST CONSUMERS ENERGY WELLNESS ROOM
FLINT MI
48506-4022
US

IV. Provider business mailing address

36296 FREDERICKSBURG RD
FARMINGTON HILLS MI
48331-3189
US

V. Phone/Fax

Practice location:
  • Phone: 810-760-3484
  • Fax: 810-760-3329
Mailing address:
  • Phone: 810-760-3484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1043
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: