1376011312 NPI number — ROMMARK BALTAZAR MANLIMOS LLMFT

Table of content: ROMMARK BALTAZAR MANLIMOS LLMFT (NPI 1376011312)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376011312 NPI number — ROMMARK BALTAZAR MANLIMOS LLMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANLIMOS
Provider First Name:
ROMMARK
Provider Middle Name:
BALTAZAR
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LLMFT
Provider Gender Code:
M

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:
1376011312
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 TORREY RD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FENTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48430-3327
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-494-7180
Provider Business Mailing Address Fax Number:
248-692-4936

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 GENOA BUSINESS PARK DR STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIGHTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48114-5328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-449-7180
Provider Business Practice Location Address Fax Number:
248-692-4936
Provider Enumeration Date:
11/07/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: 4151001008 , 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)





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