1750909503 NPI number — AH WEST BLOOMFIELD SUBTENANT, LLC

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 1750909503 NPI number — AH WEST BLOOMFIELD SUBTENANT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AH WEST BLOOMFIELD SUBTENANT, LLC
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:
1750909503
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5859 W MAPLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST BLOOMFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48322-2279
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-538-5283
Provider Business Mailing Address Fax Number:
248-538-5290

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5859 W MAPLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST BLOOMFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48322-2279
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-538-5283
Provider Business Practice Location Address Fax Number:
248-538-5290
Provider Enumeration Date:
07/08/2020

Additional Information

Authorized Official

Authorized Official Last Name:
MOCK
Authorized Official First Name:
MALLORY
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
248-538-5283

Provider Taxonomy Codes

  • Taxonomy code: 376J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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