1639307093 NPI number — AMANDA NIES D.O.

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 1639307093 NPI number — AMANDA NIES D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NIES
Provider First Name:
AMANDA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

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:
1639307093
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28595 ORCHARD LAKE RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
FARMINGTON HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48334-2977
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-553-0010
Provider Business Mailing Address Fax Number:
248-553-5957

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
577 MICHIGAN AVE STE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLLAND
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49423-4911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-396-7366
Provider Business Practice Location Address Fax Number:
616-392-2889
Provider Enumeration Date:
06/24/2009

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: 207T00000X , with the licence number:  5101018091 , 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)