1053643718 NPI number — TOTAL HEALTH ZONE SC

Table of content: (NPI 1053643718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053643718 NPI number — TOTAL HEALTH ZONE SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TOTAL HEALTH ZONE SC
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:
6
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:
1053643718
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
W8065 S US HIGHWAY 2/141
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
IRON MOUNTAIN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49801-9494
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-779-1300
Provider Business Mailing Address Fax Number:
906-779-1333

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
W8065 S US HIGHWAY 2/141
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
IRON MOUNTAIN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49801-9494
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-779-1300
Provider Business Practice Location Address Fax Number:
906-779-1333
Provider Enumeration Date:
02/05/2010

Additional Information

Authorized Official

Authorized Official Last Name:
NOWICKI
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
906-779-1300

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2341-012 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000035131 . This is a "MEDICARE ID" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 4217348 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 38844000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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