Healthcare Provider Details

I. General information

NPI: 1669862587
Provider Name (Legal Business Name): INDIVIDUAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2015
Last Update Date: 01/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2926 WALDON PARK DR
ORION MI
48359-1336
US

IV. Provider business mailing address

2926 WALDON PARK DR
ORION MI
48359-1336
US

V. Phone/Fax

Practice location:
  • Phone: 248-390-8998
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name: DR. BRIAN HATZEL
Title or Position: ASSOCIATE PROFESSOR
Credential:
Phone: 616-331-8538