Provider Demographics
NPI:1528543915
Name:SOUTHERINGTON, NATHAN CHARLES
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:CHARLES
Last Name:SOUTHERINGTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3560 LONG GROVE DR SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49512-9365
Mailing Address - Country:US
Mailing Address - Phone:616-822-4525
Mailing Address - Fax:
Practice Address - Street 1:3560 LONG GROVE DR SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49512-9365
Practice Address - Country:US
Practice Address - Phone:616-822-4525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program