Provider Demographics
NPI:1669862587
Name:INDIVIDUAL
Entity Type:Organization
Organization Name:INDIVIDUAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE PROFESSOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HATZEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-331-8538
Mailing Address - Street 1:2926 WALDON PARK DR
Mailing Address - Street 2:
Mailing Address - City:ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48359-1336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2926 WALDON PARK DR
Practice Address - Street 2:
Practice Address - City:ORION
Practice Address - State:MI
Practice Address - Zip Code:48359-1336
Practice Address - Country:US
Practice Address - Phone:248-390-8998
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-30
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty