Provider Demographics
NPI:1326001777
Name:ROCHE, MICHAEL THOMAS (ATC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:ROCHE
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Gender:M
Credentials:ATC
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Mailing Address - Street 1:6479 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:WEST OLIVE
Mailing Address - State:MI
Mailing Address - Zip Code:49460-9743
Mailing Address - Country:US
Mailing Address - Phone:616-638-0121
Mailing Address - Fax:616-234-4260
Practice Address - Street 1:143 BOSTWICK AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3201
Practice Address - Country:US
Practice Address - Phone:616-234-4260
Practice Address - Fax:616-234-4262
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-07
Last Update Date:2007-07-08
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIPROVIDER CODE 22OtherATHLETIC TRAINER