1114095510 NPI number — ADVANCED SLEEP DISORDER CENTER LLC

Table of content: (NPI 1114095510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114095510 NPI number — ADVANCED SLEEP DISORDER CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED SLEEP DISORDER CENTER 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:
1114095510
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 250681
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRANKLIN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48025-0681
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-851-1264
Provider Business Mailing Address Fax Number:
248-851-5096

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1159 E MICHIGAN AVE
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
YPSILANTI
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48198-5807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-480-4250
Provider Business Practice Location Address Fax Number:
734-480-4251
Provider Enumeration Date:
12/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PHILLIPS
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
J
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
248-851-1264

Provider Taxonomy Codes

  • Taxonomy code: 2084S0012X , with the licence number:  GA405226 , 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: 4618122 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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