Provider Demographics
NPI:1902570104
Name:WILBER, BRANDON MICHAEL (AT, ATC)
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:MICHAEL
Last Name:WILBER
Suffix:
Gender:M
Credentials:AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11134 S BAILEY VALLEY DR NE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-8330
Mailing Address - Country:US
Mailing Address - Phone:616-901-6677
Mailing Address - Fax:
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:616-234-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010024732255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer