Healthcare Provider Details

I. General information

NPI: 1023385192
Provider Name (Legal Business Name): NATHAN EDWARD DYKEMA D.P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2011
Last Update Date: 01/14/2020
Certification Date: 01/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 CHICAGO DR
HOLLAND MI
49423-3004
US

IV. Provider business mailing address

730 CHICAGO DR
HOLLAND MI
49423-3004
US

V. Phone/Fax

Practice location:
  • Phone: 616-796-6781
  • Fax: 616-796-6782
Mailing address:
  • Phone: 616-796-6781
  • Fax: 616-796-6782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number5501015768
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: