Provider Demographics
NPI:1477600963
Name:HAWTHORNE, GREGORY DALE JR (ATC)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:DALE
Last Name:HAWTHORNE
Suffix:JR
Gender:M
Credentials:ATC
Other - Prefix:
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Mailing Address - Street 1:4495 HERITAGE AVE APT B3
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-3309
Mailing Address - Country:US
Mailing Address - Phone:734-834-7862
Mailing Address - Fax:
Practice Address - Street 1:JENISON FIELDHOUSE
Practice Address - Street 2:MICHIGAN STATE UNIVERSITY
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823
Practice Address - Country:US
Practice Address - Phone:517-355-1627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer