1124061353 NPI number — SSC FENTON OPERATING COMPANY LLC

Table of content: (NPI 1124061353)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124061353 NPI number — SSC FENTON OPERATING COMPANY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SSC FENTON OPERATING COMPANY 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:
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:
1124061353
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5300 W SAM HOUSTON PKWY N
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77041-5161
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-467-6000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 TREALOUT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FENTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48430-1481
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-629-4105
Provider Business Practice Location Address Fax Number:
810-629-7538
Provider Enumeration Date:
06/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SANTORO
Authorized Official First Name:
KELLE
Authorized Official Middle Name:
C
Authorized Official Title or Position:
SR DIRECTOR AR
Authorized Official Telephone Number:
832-467-5728

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  254210 , 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: 4882204 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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