Provider Demographics
NPI:1588203293
Name:WENK, EARL (LAT ATC)
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:
Last Name:WENK
Suffix:
Gender:M
Credentials:LAT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4237 LAKE FOREST DR E
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-9681
Mailing Address - Country:US
Mailing Address - Phone:734-730-9300
Mailing Address - Fax:
Practice Address - Street 1:1958 S INDUSTRIAL HWY STE C
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-4625
Practice Address - Country:US
Practice Address - Phone:734-585-0449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-27
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010008882255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer