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NPI Code Detail

MEDICARE: MR. JOHN MIRAM MCCLEVE IV

MEDICARE: MR. JOHN MIRAM MCCLEVE IV
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12255A2300XAthletic Trainer
2390200000XStudent in an Organized Health Care Education/Training Program

General Provider Information

NPI Number : 1265826077
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. JOHN MIRAM MCCLEVE IV
Provider Business Mailing Address
First Line : 7679 BLUE LAKE RD
Second Line :
City : TWIN LAKE
State : MI
Zip : 49457-9408
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 7679 BLUE LAKE RD
Second Line :
City : TWIN LAKE
State : MI
Zip : 49457
Country : US
Telephone Number : 616-490-1740
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/19/2015
Last Update Date : 03/19/2015

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