=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295345056
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DELAND MAURICE MCMULLAN JR.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2020
-----------------------------------------------------
Last Update Date | 08/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1122 WALNUT ST
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48198-3937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-320-4819
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 970646
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48197-0088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-320-4819
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 1258592
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------