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General NPI Number Information
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NPI Number | 1588203293
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Entity Type | Individual
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Provider Name | EARL WENK LAT ATC
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Gender | Male
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Dates
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Enumeration Date | 12/27/2019
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Last Update Date | 12/27/2019
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Provider Practice Location Address
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Address Line | 1958 S INDUSTRIAL HWY STE C
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City | ANN ARBOR
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State | MI
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Zip | 48104-4625
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Country | US
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Telephone | 734-585-0449
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Fax |
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Provider Business Mailing Address
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Address Line | 4237 LAKE FOREST DR E
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City | ANN ARBOR
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State | MI
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Zip | 48108-9681
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Country | US
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Telephone | 734-730-9300
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2601000888
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License Number State | MI
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