1033619572 NPI number — RIVERS EDGE RECOVERY CENTER OF MICHIGAN LLC

Table of content: (NPI 1033619572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033619572 NPI number — RIVERS EDGE RECOVERY CENTER OF MICHIGAN LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERS EDGE RECOVERY CENTER OF MICHIGAN 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:
1033619572
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MASON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48854-0010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-676-9788
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
916 WASHINGTON AVE STE 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAY CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48708-5721
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-415-3143
Provider Business Practice Location Address Fax Number:
989-391-4412
Provider Enumeration Date:
02/20/2018

Additional Information

Authorized Official

Authorized Official Last Name:
HOUPT
Authorized Official First Name:
MARY BETH
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING
Authorized Official Telephone Number:
517-676-9788

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  6801068319 , 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)





Copyright © 2007-2025 www.npivalidator.com