Provider Demographics
NPI:1538939863
Name:ANDRETICH, GEORGE NICHOLAS
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:NICHOLAS
Last Name:ANDRETICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16044 W PENNYROYAL LN
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441
Mailing Address - Country:US
Mailing Address - Phone:708-846-2405
Mailing Address - Fax:
Practice Address - Street 1:1200 S FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48859-2001
Practice Address - Country:US
Practice Address - Phone:989-774-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer