Provider Demographics
NPI:1881059251
Name:MACDONALD, ELIZA (MPA, AT, ATC)
Entity type:Individual
Prefix:
First Name:ELIZA
Middle Name:
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:MPA, AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11247 RED HAWK LN
Mailing Address - Street 2:
Mailing Address - City:ALLENDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49401-8071
Mailing Address - Country:US
Mailing Address - Phone:616-304-1686
Mailing Address - Fax:
Practice Address - Street 1:1 CAMPUS DR
Practice Address - Street 2:KHS 4418
Practice Address - City:ALLENDALE
Practice Address - State:MI
Practice Address - Zip Code:49401-9401
Practice Address - Country:US
Practice Address - Phone:616-331-8877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer