Provider Demographics
NPI:1710424833
Name:OHLEN, MICAH GREGORY KAI (ATC)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:GREGORY KAI
Last Name:OHLEN
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 1:29211 STALLION RDG
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-3602
Mailing Address - Country:US
Mailing Address - Phone:805-331-6009
Mailing Address - Fax:
Practice Address - Street 1:29211 STALLION RDG
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-3602
Practice Address - Country:US
Practice Address - Phone:805-331-6009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2000015732390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program