Provider Demographics
NPI:1508307273
Name:CENTRAL MICHIGAN UNIVERSITY
Entity Type:Organization
Organization Name:CENTRAL MICHIGAN UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE ATHLETIC TRAINER
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:AT, ATC
Authorized Official - Phone:989-774-6687
Mailing Address - Street 1:1617 FESSENDEN AVE
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-2137
Mailing Address - Country:US
Mailing Address - Phone:989-774-6687
Mailing Address - Fax:989-774-1095
Practice Address - Street 1:203 E BROOMFIELD
Practice Address - Street 2:ROSE 145
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48859-0001
Practice Address - Country:US
Practice Address - Phone:989-774-6687
Practice Address - Fax:989-774-1095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2601000874305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service