1205001807 NPI number — JEFFREY E. FANTICH, DC, PLC

Table of content: (NPI 1205001807)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205001807 NPI number — JEFFREY E. FANTICH, DC, PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JEFFREY E. FANTICH, DC, PLC
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:
1205001807
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6022 W MAPLE RD
Provider Second Line Business Mailing Address:
SUITE 405
Provider Business Mailing Address City Name:
WEST BLOOMFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48322-4408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-737-8066
Provider Business Mailing Address Fax Number:
248-737-9093

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6022 W MAPLE RD
Provider Second Line Business Practice Location Address:
SUITE 405
Provider Business Practice Location Address City Name:
WEST BLOOMFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48322-4408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-737-8066
Provider Business Practice Location Address Fax Number:
248-737-9093
Provider Enumeration Date:
04/24/2008

Additional Information

Authorized Official

Authorized Official Last Name:
FANTICH
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
248-737-8066

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2301006930 , 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: 0F35177 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com