1881366938 NPI number — HARLEY RENEE MASUMOTO

Table of content: HARLEY RENEE MASUMOTO (NPI 1881366938)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881366938 NPI number — HARLEY RENEE MASUMOTO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MASUMOTO
Provider First Name:
HARLEY
Provider Middle Name:
RENEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EDMONDS
Provider Other First Name:
HARLEY
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1881366938
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20500 STAFFORD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLINTON TOWNSHIP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48035-4067
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-563-5234
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
33464 SCHOENHERR RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STERLING HEIGHTS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48312-6314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-275-2478
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/28/2021

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: 106S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 156F00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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