=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407632359
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY ALAN TUSCH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2023
-----------------------------------------------------
Last Update Date | 09/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8028 THERESE CT SE
-----------------------------------------------------
City | CALEDONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49316-8972
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-719-6794
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8028 THERESE CT SE
-----------------------------------------------------
City | CALEDONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49316-8972
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-719-6794
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171400000X
-----------------------------------------------------
Taxonomy Name | Health & Wellness Coach
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------