Provider Demographics
NPI:1124579297
Name:TETREAULT-BLOK, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:TETREAULT-BLOK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7781 BURLINGAME AVE. S.W.
Mailing Address - Street 2:
Mailing Address - City:BYRON CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49315
Mailing Address - Country:US
Mailing Address - Phone:616-878-0090
Mailing Address - Fax:
Practice Address - Street 1:7781 BURLINGAME AVE SW
Practice Address - Street 2:
Practice Address - City:BYRON CENTER
Practice Address - State:MI
Practice Address - Zip Code:49315-9060
Practice Address - Country:US
Practice Address - Phone:616-878-0090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other