Healthcare Provider Details

I. General information

NPI: 1750407359
Provider Name (Legal Business Name): TIMOTHY ROBERT KOBERNA ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 01/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 FAIRBANKS AVE DEPT. OF KINESIOLOGY HOPE COLLEGE
HOLLAND MI
49423-3735
US

IV. Provider business mailing address

222 FAIRBANKS AVE DEPT. OF KINESIOLOGY HOPE COLLEGE
HOLLAND MI
49423-3735
US

V. Phone/Fax

Practice location:
  • Phone: 616-395-7705
  • Fax: 616-395-7087
Mailing address:
  • Phone: 616-395-7705
  • Fax: 616-395-7087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601001150
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: