Healthcare Provider Details

I. General information

NPI: 1477565158
Provider Name (Legal Business Name): JESSE ROBERT BRINKS ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4451 HUNSBERGER AVE NE
GRAND RAPIDS MI
49525-6126
US

IV. Provider business mailing address

3740 GRANT ST
HUDSONVILLE MI
49426-1205
US

V. Phone/Fax

Practice location:
  • Phone: 616-363-4857
  • Fax: 616-361-3494
Mailing address:
  • Phone: 616-824-6542
  • Fax: 616-361-3494

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: