Provider Demographics
NPI:1740601046
Name:VOGEL, BRENT (ATC)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:VOGEL
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 1:530 CEDAR RIDGE DR NW APT 3A
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49544-8512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:530 CEDAR RIDGE DR NW APT 3A
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-8512
Practice Address - Country:US
Practice Address - Phone:616-893-8786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-04
Last Update Date:2014-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010010592255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer