Healthcare Provider Details

I. General information

NPI: 1245740174
Provider Name (Legal Business Name): TARYN BUSHONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2017
Last Update Date: 10/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16456 OAKLEAF CT
HOLLAND MI
49424-5622
US

IV. Provider business mailing address

16456 OAKLEAF CT
HOLLAND MI
49424-5622
US

V. Phone/Fax

Practice location:
  • Phone: 616-566-0060
  • Fax:
Mailing address:
  • Phone: 616-786-0216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberB252785676772
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberB252785676772
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: