Provider Demographics
NPI:1568864379
Name:ANTHONY, NICK (ATC)
Entity Type:Individual
Prefix:
First Name:NICK
Middle Name:
Last Name:ANTHONY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14833 SANTA ANITA AVE
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-3991
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2432 N DRAKE RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-1361
Practice Address - Country:US
Practice Address - Phone:734-536-5781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-24
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010010892255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer