1558527390 NPI number — COVENTRY HOMESTEAD, LLC

Table of content: (NPI 1558527390)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558527390 NPI number — COVENTRY HOMESTEAD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COVENTRY HOMESTEAD, 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:
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:
1558527390
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19402 COVENTRY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48203-4909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-368-4649
Provider Business Mailing Address Fax Number:
313-368-4649

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19402 COVENTRY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48203-4909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-368-4649
Provider Business Practice Location Address Fax Number:
313-368-4649
Provider Enumeration Date:
07/31/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BONEY
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
313-368-4649

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X , with the licence number:  AS820289860 , 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)