Healthcare Provider Details

I. General information

NPI: 1528317971
Provider Name (Legal Business Name): MATTHEW VINNAL ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2012
Last Update Date: 08/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 LAKE DR SE SUITE 305
GRAND RAPIDS MI
49546-8292
US

IV. Provider business mailing address

247 E 8TH ST
CLIFTON NJ
07011-1775
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-8860
  • Fax: 616-267-8442
Mailing address:
  • Phone: 970-306-8804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: