1013187541 NPI number — HERON RIDGE ASSOCIATES, PLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013187541 NPI number — HERON RIDGE ASSOCIATES, PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HERON RIDGE ASSOCIATES, PLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013187541
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3694 CLARKSTON RD
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
CLARKSTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48348-5213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-693-8880
Provider Business Mailing Address Fax Number:
248-391-7478

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31000 TELEGRAPH RD
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
BINGHAM FARMS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48025-4360
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-594-4991
Provider Business Practice Location Address Fax Number:
248-391-7478
Provider Enumeration Date:
03/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
RICHELSON
Authorized Official First Name:
ELLIOTT
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT, SECRETARY, TREASURER
Authorized Official Telephone Number:
904-605-4986

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  631056 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 463240 . This is a "VALUE OPTIONS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 750910409 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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