Healthcare Provider Details

I. General information

NPI: 1174012280
Provider Name (Legal Business Name): COLLIN JACOB KARCHER AT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2018
Last Update Date: 05/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 GROSSE POINTE BLVD
GROSSE POINTE FARMS MI
48236-3711
US

IV. Provider business mailing address

48491 SUGARBUSH RD
CHESTERFIELD MI
48047-3325
US

V. Phone/Fax

Practice location:
  • Phone: 313-432-3581
  • Fax: 313-432-3544
Mailing address:
  • Phone: 810-247-1011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601001812
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: