Provider Demographics
NPI:1306397864
Name:BERNAL, JOHN (ATC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BERNAL
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 FULTON ST W
Mailing Address - Street 2:#111
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2682
Mailing Address - Country:US
Mailing Address - Phone:616-831-6422
Mailing Address - Fax:
Practice Address - Street 1:130 FULTON ST W
Practice Address - Street 2:#111
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2682
Practice Address - Country:US
Practice Address - Phone:616-831-6422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010009262255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer