1043308398 NPI number — LUANN ETCHER N.P.

Table of content: LUANN ETCHER N.P. (NPI 1043308398)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043308398 NPI number — LUANN ETCHER N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ETCHER
Provider First Name:
LUANN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
N.P.
Provider Gender Code:
F

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:
1043308398
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6149 N WAYNE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTLAND
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48185-7128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-728-2130
Provider Business Mailing Address Fax Number:
734-728-2626

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6150 OAK TREE BLVD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
INDEPENDENCE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44131-6917
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-897-9177
Provider Business Practice Location Address Fax Number:
800-470-8713
Provider Enumeration Date:
10/11/2006

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: 363L00000X , with the licence number:  4704155261 , 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: 4583018 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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