Provider Demographics
NPI:1922093418
Name:HORNBUCKLE, MICHAEL GLENN (ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:GLENN
Last Name:HORNBUCKLE
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5023 W 92ND AVE
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-1677
Mailing Address - Country:US
Mailing Address - Phone:219-924-3512
Mailing Address - Fax:
Practice Address - Street 1:9711 VALPARAISO DR
Practice Address - Street 2:SUITE #1
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2866
Practice Address - Country:US
Practice Address - Phone:219-924-3512
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001065A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer