Provider Demographics
NPI:1346628534
Name:EASTERN MICHIGAN UNIVERSITY
Entity Type:Organization
Organization Name:EASTERN MICHIGAN UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATHLETIC TRAINER
Authorized Official - Prefix:
Authorized Official - First Name:NIKOLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:ATC
Authorized Official - Phone:612-242-2676
Mailing Address - Street 1:PO BOX 446
Mailing Address - Street 2:
Mailing Address - City:LESTER PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55354-0446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:799 N HEWITT RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1701
Practice Address - Country:US
Practice Address - Phone:734-487-5179
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-08
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3667518302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization