Healthcare Provider Details

I. General information

NPI: 1750774865
Provider Name (Legal Business Name): TAYLOR EASTON WITCZAK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2015
Last Update Date: 12/22/2019
Certification Date: 12/22/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12735 THERIS DR
WAYLAND MI
49348-9214
US

IV. Provider business mailing address

12735 THERIS DR
WAYLAND MI
49348-9214
US

V. Phone/Fax

Practice location:
  • Phone: 616-485-5197
  • Fax:
Mailing address:
  • Phone: 616-485-5197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501019293
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: