1437488921 NPI number — PURE JOY PEDIATRICS, P.C.

Table of content: (NPI 1437488921)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437488921 NPI number — PURE JOY PEDIATRICS, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PURE JOY PEDIATRICS, P.C.
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:
1437488921
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
36880 WOODWARD AVE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
BLOOMFIELD HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48304-0919
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-220-2384
Provider Business Mailing Address Fax Number:
248-630-2627

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
36880 WOODWARD AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
BLOOMFIELD HILLS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48304-0919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-220-2384
Provider Business Practice Location Address Fax Number:
248-630-2627
Provider Enumeration Date:
12/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HENDRICKS
Authorized Official First Name:
LA DONNA
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
248-421-9706

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  4301088258 , 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: 1952509838 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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