1215242763 NPI number — BARUCH SLS, INC

Table of content: (NPI 1215242763)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215242763 NPI number — BARUCH SLS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BARUCH SLS, 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:
1215242763
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3196 KRAFT AVE SE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49512-2078
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-464-1564
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16331 ROBBINS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND HAVEN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49417-8903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-847-4242
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/09/2010

Additional Information

Authorized Official

Authorized Official Last Name:
DARWIN
Authorized Official First Name:
MISSY
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
616-847-4242

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  AL700007383 , 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: 23D2004740 . This is a "CLIA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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