1285127795 NPI number — IAN MIKEL HOEFELMEYER

Table of content: IAN MIKEL HOEFELMEYER (NPI 1285127795)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285127795 NPI number — IAN MIKEL HOEFELMEYER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOEFELMEYER
Provider First Name:
IAN
Provider Middle Name:
MIKEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1285127795
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1238 QUARRY AVE NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49504-3132
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-622-1595
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 RENAISSANCE CTR STE 2600
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:
48243-1502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-832-6727
Provider Business Practice Location Address Fax Number:
772-676-9100
Provider Enumeration Date:
06/08/2018

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: 247200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106S00000X , 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)

  • Identifier: 247200000X . This is a "POSITIVE BEHAVIOR SUPPORT CORP." identifier . This identifiers is of the category "OTHER".
  • Identifier: 106S00000X , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".