1124342852 NPI number — ANGELS OF THE HEART

Table of content: (NPI 1124342852)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124342852 NPI number — ANGELS OF THE HEART

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANGELS OF THE HEART
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:
1124342852
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17373 ROXBURY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48075-7610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-761-7452
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18870 CHURCH HILL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERVIEW
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48193-1702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-589-2313
Provider Business Practice Location Address Fax Number:
734-225-6495
Provider Enumeration Date:
03/24/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RANDALL
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
IRA
Authorized Official Title or Position:
CONSULTANT
Authorized Official Telephone Number:
313-529-7002

Provider Taxonomy Codes

  • Taxonomy code: 320800000X , with the licence number:  AS80294958 , 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)