Healthcare Provider Details

I. General information

NPI: 1114097474
Provider Name (Legal Business Name): JOHN NIEMELA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 03/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 N 3RD ST SUITE #6
MARQUETTE MI
49855-3500
US

IV. Provider business mailing address

1015 N 3RD STREET STE 6
MARQUETTE MI
49855-3500
US

V. Phone/Fax

Practice location:
  • Phone: 906-225-0181
  • Fax: 906-225-0340
Mailing address:
  • Phone: 906-225-0181
  • Fax: 906-225-0340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number5901002208
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5901002208
License Number StateMI

VIII. Authorized Official

Name: JOHN D NIEMELA
Title or Position: PHYSICIAN OWNER
Credential: DPM
Phone: 906-225-0181