1073803250 NPI number — HOLLY YORK LLC

Table of content: (NPI 1073803250)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073803250 NPI number — HOLLY YORK LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOLLY YORK LLC
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:
SPINAL CARE CENTER
Provider Other Organization Name Type Code:
3
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:
1073803250
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3138 BROADMOOR AVE SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENTWOOD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49512-1845
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-575-9105
Provider Business Mailing Address Fax Number:
616-575-9107

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3138 BROADMOOR AVE SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENTWOOD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49512-1845
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-575-9105
Provider Business Practice Location Address Fax Number:
616-575-9107
Provider Enumeration Date:
04/08/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
YORK
Authorized Official First Name:
HOLLY
Authorized Official Middle Name:
ELIZEBETH
Authorized Official Title or Position:
OWNER/CHIROPRACTOR
Authorized Official Telephone Number:
616-530-7474

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2301009429 , 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: 1376728568 . This is a "MEDICAID INDIVIDUAL ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1922191048 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".