Provider Demographics
NPI:1457628018
Name:GNACINSKI, MICHAEL R (ATC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:R
Last Name:GNACINSKI
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2743
Mailing Address - Street 2:1140 EDWARDS VILLAGE B-105
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-2743
Mailing Address - Country:US
Mailing Address - Phone:970-569-3240
Mailing Address - Fax:970-659-3260
Practice Address - Street 1:1140 EDWARDS VILLAGE BUILDING 105
Practice Address - Street 2:
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632
Practice Address - Country:US
Practice Address - Phone:970-569-3240
Practice Address - Fax:970-569-3260
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7832255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer