Healthcare Provider Details

I. General information

NPI: 1588431191
Provider Name (Legal Business Name): TRISTAN TERRANCE FOUST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2023
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

636 1ST ST NW APT 304
GRAND RAPIDS MI
49504-5828
US

IV. Provider business mailing address

636 1ST ST NW APT 304
GRAND RAPIDS MI
49504-5828
US

V. Phone/Fax

Practice location:
  • Phone: 616-655-3483
  • Fax:
Mailing address:
  • Phone: 616-655-3483
  • 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: