1457416406 NPI number — MR. DAMON O COLLIER P.T.

Table of content: MR. DAMON O COLLIER P.T. (NPI 1457416406)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457416406 NPI number — MR. DAMON O COLLIER P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLLIER
Provider First Name:
DAMON
Provider Middle Name:
O
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1457416406
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
49445 GOLDEN GATE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MACOMB
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48044-5498
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-321-7606
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23829 LITTLE MACK AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SAINT CLAIR SHORES
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48080-1186
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-416-4281
Provider Business Practice Location Address Fax Number:
586-412-8757
Provider Enumeration Date:
12/27/2006

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: 225100000X , with the licence number:  5501010002 , 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: P33330002 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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