Healthcare Provider Details

I. General information

NPI: 1063082261
Provider Name (Legal Business Name): JALEN CATES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2021
Last Update Date: 08/28/2021
Certification Date: 08/28/2021
Deactivation Date: 07/05/2021
Reactivation Date: 08/20/2021

III. Provider practice location address

3111 ELECTRIC AVE
PORT HURON MI
48060-8127
US

IV. Provider business mailing address

2540 TAYLOR DR
KIMBALL MI
48074-1128
US

V. Phone/Fax

Practice location:
  • Phone: 810-985-8900
  • Fax:
Mailing address:
  • Phone: 810-300-7855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: