1134217268 NPI number — MRS. WENDY MARIE SOBERG SIT OTRL

Table of content: MRS. WENDY MARIE SOBERG SIT OTRL (NPI 1134217268)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134217268 NPI number — MRS. WENDY MARIE SOBERG SIT OTRL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIT
Provider First Name:
WENDY
Provider Middle Name:
MARIE SOBERG
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTRL
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SIMPSON
Provider Other First Name:
WENDY
Provider Other Middle Name:
MARIE SOBERG
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTRL
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1134217268
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4740 CROOKED LAKE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOWELL
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48843-8812
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-308-7987
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
36975 5 MILE RD
Provider Second Line Business Practice Location Address:
MARYWOOD NURSING CARE CENTER
Provider Business Practice Location Address City Name:
LIVONIA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48154-1871
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-464-0600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/11/2006

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: 225X00000X , with the licence number:  5201007566 , 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)





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