1952431777 NPI number — METROPOLITAN ARTS COMPLEX INC

Table of content: (NPI 1952431777)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952431777 NPI number — METROPOLITAN ARTS COMPLEX INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
METROPOLITAN ARTS COMPLEX INC
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:
METRO ARTS THERAPY SERVICES
Provider Other Organization Name Type Code:
3
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:
1952431777
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11000 W. MCNICHOLS
Provider Second Line Business Mailing Address:
SUITE B3 & B4
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48221-2357
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-863-5554
Provider Business Mailing Address Fax Number:
313-863-4711

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11000 W. MCNICHOLS
Provider Second Line Business Practice Location Address:
SUITE B3 & B4
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-863-5554
Provider Business Practice Location Address Fax Number:
313-863-4711
Provider Enumeration Date:
03/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MANDINGO
Authorized Official First Name:
AMELITA
Authorized Official Middle Name:
LEVON
Authorized Official Title or Position:
EXECUTIVE DIRECTOR & CLINICIAN
Authorized Official Telephone Number:
313-863-5554

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  6401010525 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 6401010525 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0850X , with the licence number: 6401010525 , 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: 31-3204514 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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