1679775308 NPI number — CHOCTAW MANAGEMENT SERVICES ENTERPRISE

Table of content: (NPI 1679775308)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679775308 NPI number — CHOCTAW MANAGEMENT SERVICES ENTERPRISE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHOCTAW MANAGEMENT SERVICES ENTERPRISE
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:
1679775308
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2773 MAYFAIR DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48084-2601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-649-1042
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1172 KIRTS BLVD
Provider Second Line Business Practice Location Address:
U.S. MEPS
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48084-4846
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-244-9131
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HUMPHREY
Authorized Official First Name:
AMY
Authorized Official Middle Name:
Authorized Official Title or Position:
PROGRAM COORDINATOR
Authorized Official Telephone Number:
877-267-3728

Provider Taxonomy Codes

  • Taxonomy code: 171000000X , with the licence number:  4301037778 , 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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