1083094874 NPI number — CHOICE CARE SERVICES, INC.

Table of content: MARIAN ELIZABETH SHUSTOV LMT (NPI 1073012233)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083094874 NPI number — CHOICE CARE SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHOICE CARE SERVICES, 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:
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:
1083094874
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18121 E 8 MILE RD
Provider Second Line Business Mailing Address:
#303
Provider Business Mailing Address City Name:
EASTPOINTE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48021-3245
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-656-2409
Provider Business Mailing Address Fax Number:
313-656-2411

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18121 E 8 MILE RD
Provider Second Line Business Practice Location Address:
#303
Provider Business Practice Location Address City Name:
EASTPOINTE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48021-3245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-656-2409
Provider Business Practice Location Address Fax Number:
313-656-2411
Provider Enumeration Date:
06/05/2015

Additional Information

Authorized Official

Authorized Official Last Name:
MCDANIELS
Authorized Official First Name:
TASSIE
Authorized Official Middle Name:
SHENITA
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
313-510-1625

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X , with the licence number:  4704154830 , 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: 6947086 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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