Healthcare Provider Details

I. General information

NPI: 1225542301
Provider Name (Legal Business Name): CRAIG ALVIN PLONKA ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2017
Last Update Date: 11/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19556 HARPER AVE
HARPER WOODS MI
48225-2037
US

IV. Provider business mailing address

8928 LOUISE ST
LIVONIA MI
48150-4016
US

V. Phone/Fax

Practice location:
  • Phone: 313-885-6491
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601001171
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: