Healthcare Provider Details

I. General information

NPI: 1316569866
Provider Name (Legal Business Name): MICHAEL JAMISON TREMBLAY MS, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2020
Last Update Date: 05/07/2020
Certification Date: 05/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALDWELL FIELDHOUSE PRINCETON UNIVERSITY CAMPUS
PRINCETON NJ
08544-0001
US

IV. Provider business mailing address

28108 CHERRY BLOSSOM CT
LAWRENCE TOWNSHIP NJ
08648-1287
US

V. Phone/Fax

Practice location:
  • Phone: 609-258-3527
  • Fax:
Mailing address:
  • Phone: 774-644-9768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00270600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: