1891822375 NPI number — MR. STEPHEN JAMES NORDWALL ATC

Table of content: MR. STEPHEN JAMES NORDWALL ATC (NPI 1891822375)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891822375 NPI number — MR. STEPHEN JAMES NORDWALL ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NORDWALL
Provider First Name:
STEPHEN
Provider Middle Name:
JAMES
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
ATC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891822375
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4213 INVERNESS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEXTER
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48130-1460
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-904-0711
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
799 N. HEWITT ROAD
Provider Second Line Business Practice Location Address:
CONVOCATION CENTER - ATHLETIC DEPARTMENT
Provider Business Practice Location Address City Name:
YPSILANTI
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48197
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-487-5183
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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