1942468780 NPI number — WOLVERINE SLEEP PLLC

Table of content: (NPI 1942468780)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942468780 NPI number — WOLVERINE SLEEP PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOLVERINE SLEEP PLLC
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:
1942468780
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
411 E RUSSELL RD
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
TECUMSEH
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49286-7502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-424-8286
Provider Business Mailing Address Fax Number:
517-470-0296

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23353 US HWY 82 W
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
SHERMAN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75092
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-786-2621
Provider Business Practice Location Address Fax Number:
903-786-2634
Provider Enumeration Date:
05/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GORCZYCA
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
517-424-8286

Provider Taxonomy Codes

  • Taxonomy code: 261QS1200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PL7268 . This is a "BCBS OF TEXAS" identifier . This identifiers is of the category "OTHER".




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