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General NPI Number Information
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NPI Number | 1801293865
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Entity Type | Individual
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Provider Name | WILLIAM JASON BURGESS IV MS, AT, ATC, CSCS
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Gender | Male
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Dates
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Enumeration Date | 11/19/2014
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Last Update Date | 11/19/2014
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Provider Practice Location Address
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Address Line | 3333 96TH AVE
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City | ZEELAND
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State | MI
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Zip | 49464-9721
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Country | US
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Telephone | 616-748-3129
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Fax | 616-748-3196
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Provider Business Mailing Address
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Address Line | 3333 96TH AVE
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City | ZEELAND
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State | MI
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Zip | 49464-9721
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Country | US
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Telephone | 616-748-3129
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Fax | 616-748-3196
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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 | 2601001292
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License Number State | MI
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