Healthcare Provider Details

I. General information

NPI: 1972196285
Provider Name (Legal Business Name): MR. VINSON CARL CANDELA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2021
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4290 MILLER RD STE 4
FLINT MI
48507-1283
US

IV. Provider business mailing address

13121 GRANT CIR
CLIO MI
48420-8100
US

V. Phone/Fax

Practice location:
  • Phone: 810-285-9765
  • 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: