1154538619 NPI number — ALLERGY CLINIC OF LIVINGSTON COUNTY PC

Table of content: (NPI 1154538619)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154538619 NPI number — ALLERGY CLINIC OF LIVINGSTON COUNTY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALLERGY CLINIC OF LIVINGSTON COUNTY PC
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:
1154538619
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8619 W GRAND RIVER AVE
Provider Second Line Business Mailing Address:
STE. J
Provider Business Mailing Address City Name:
BRIGHTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48116-2334
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-227-6793
Provider Business Mailing Address Fax Number:
810-227-5397

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8619 W GRAND RIVER AVE
Provider Second Line Business Practice Location Address:
STE. J
Provider Business Practice Location Address City Name:
BRIGHTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48116-2334
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-227-6793
Provider Business Practice Location Address Fax Number:
810-227-5397
Provider Enumeration Date:
05/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ZACKS
Authorized Official First Name:
MARK
Authorized Official Middle Name:
N
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
810-227-6793

Provider Taxonomy Codes

  • Taxonomy code: 207K00000X , with the licence number:  MZ035093 , 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: 4840320 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2924 . This is a "GREAT LAKES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 700D711040 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: M011067 . This is a "CHAMPUS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 11217890 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 700D711040 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 93648A . This is a "HAP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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