Provider Demographics
NPI:1528394079
Name:TRUMBULL, TOM KENNETH IV (DPT)
Entity Type:Individual
Prefix:DR
First Name:TOM
Middle Name:KENNETH
Last Name:TRUMBULL
Suffix:IV
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:950 TAYLOR AVE STE 180
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2281
Mailing Address - Country:US
Mailing Address - Phone:616-200-4428
Mailing Address - Fax:616-200-4436
Practice Address - Street 1:950 TAYLOR AVE STE 180
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2282
Practice Address - Country:US
Practice Address - Phone:616-200-4428
Practice Address - Fax:616-200-4436
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-19
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014850225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty