Provider Demographics
NPI:1669067195
Name:MAKEDONSKY, SAMUEL WAYNE (LMT)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:WAYNE
Last Name:MAKEDONSKY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3360 CRANBERRY DR
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:MI
Mailing Address - Zip Code:48049-4402
Mailing Address - Country:US
Mailing Address - Phone:810-662-6155
Mailing Address - Fax:
Practice Address - Street 1:125 E CAPAC RD
Practice Address - Street 2:
Practice Address - City:IMLAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48444-1111
Practice Address - Country:US
Practice Address - Phone:810-724-0996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-06
Last Update Date:2021-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501011914225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist