1043368806 NPI number — CHARMAIN ROSE ZAPOTOCZNY LA FOUNTAIN MSW

Table of content: CHARMAIN ROSE ZAPOTOCZNY LA FOUNTAIN MSW (NPI 1043368806)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043368806 NPI number — CHARMAIN ROSE ZAPOTOCZNY LA FOUNTAIN MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LA FOUNTAIN
Provider First Name:
CHARMAIN
Provider Middle Name:
ROSE ZAPOTOCZNY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ZAPOTOCZNY
Provider Other First Name:
CHARMAIN
Provider Other Middle Name:
ROSE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1043368806
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6 PARKLANE BLVD.
Provider Second Line Business Mailing Address:
SUITE 695
Provider Business Mailing Address City Name:
DEARBORN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48126
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-271-8170
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6 PARKLANE BLVD
Provider Second Line Business Practice Location Address:
SUITE 695
Provider Business Practice Location Address City Name:
DEARBORN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48126-2696
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-271-8170
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8008970120 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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