Provider Demographics
NPI:1659640035
Name:GOULD, JOHN NICHOLAS
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:NICHOLAS
Last Name:GOULD
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 1:17288 180TH AVE
Mailing Address - Street 2:
Mailing Address - City:LEROY
Mailing Address - State:MI
Mailing Address - Zip Code:49655-8420
Mailing Address - Country:US
Mailing Address - Phone:231-388-0018
Mailing Address - Fax:
Practice Address - Street 1:17288 180TH AVE
Practice Address - Street 2:
Practice Address - City:LEROY
Practice Address - State:MI
Practice Address - Zip Code:49655-8420
Practice Address - Country:US
Practice Address - Phone:231-388-0018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF670277211172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI123456789OtherSHADY PINES AFC HOME