Healthcare Provider Details

I. General information

NPI: 1629408091
Provider Name (Legal Business Name): ANTHONY JOHN CILLUFFO MS, AT, ATC, CEIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2013
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 DENDRINOS DR STE 102
TRAVERSE CITY MI
49684-8895
US

IV. Provider business mailing address

1 CAMPUS DR 2015 JAMES H. ZUMBERGE HALL
ALLENDALE MI
49401-9403
US

V. Phone/Fax

Practice location:
  • Phone: 616-331-5700
  • Fax: 616-331-5999
Mailing address:
  • Phone: 616-331-5700
  • Fax: 616-331-5999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601001019
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: