Healthcare Provider Details

I. General information

NPI: 1396287231
Provider Name (Legal Business Name): JOSHUA TENNYCK ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2016
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1916 EAST G AVE
PARCHMENT MI
49004
US

IV. Provider business mailing address

5705 BROOKHAVEN DRIVE
RACINE WI
53406
US

V. Phone/Fax

Practice location:
  • Phone: 269-488-1100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601001699
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: