Organization
EASTERN MICHIGAN UNIVERSITY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
NIKOLIS GUSTAFSON ATC (ATHLETIC TRAINER)
(612) 242-2676
Entity
Organization
Contact information
Practice address
799 N HEWITT RD, YPSILANTI, MI 48197-1701
(734) 487-5179
Mailing address
PO BOX 446, LESTER PRAIRIE, MN 55354-0446
Taxonomy
Speciality
Code
Description
License number
State
302R00000X
Health Maintenance Organization
Primary
3667518
MI
Other
Enumeration date
05/08/2015
Last updated
05/08/2015
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