Healthcare Provider Details

I. General information

NPI: 1306397864
Provider Name (Legal Business Name): JOHN BERNAL ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 10/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 FULTON ST W #111
GRAND RAPIDS MI
49503-2682
US

IV. Provider business mailing address

130 FULTON ST W #111
GRAND RAPIDS MI
49503-2682
US

V. Phone/Fax

Practice location:
  • Phone: 616-831-6422
  • Fax:
Mailing address:
  • Phone: 616-831-6422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601000926
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: