Healthcare Provider Details

I. General information

NPI: 1427925171
Provider Name (Legal Business Name): MR. KONNOR KUPPE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2025
Last Update Date: 10/18/2025
Certification Date: 10/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56788 MOUND RD
SHELBY TWP MI
48316-4942
US

IV. Provider business mailing address

56788 MOUND RD
SHELBY TWP MI
48316-4942
US

V. Phone/Fax

Practice location:
  • Phone: 586-345-0037
  • Fax:
Mailing address:
  • Phone: 586-345-0037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: