Healthcare Provider Details

I. General information

NPI: 1932602257
Provider Name (Legal Business Name): SALLY ANN DULL CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 03/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 NASHVILLE RD
HASTINGS MI
49058-8824
US

IV. Provider business mailing address

2700 NASHVILLE RD
HASTINGS MI
49058-8824
US

V. Phone/Fax

Practice location:
  • Phone: 269-945-1301
  • Fax:
Mailing address:
  • Phone: 269-945-1301
  • Fax: 269-945-5380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: