1457896896 NPI number — AHI MEDICAL ADDICTIONS CLINIC, LLC

Table of content: (NPI 1457896896)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457896896 NPI number — AHI MEDICAL ADDICTIONS CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AHI MEDICAL ADDICTIONS CLINIC, LLC
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:
1457896896
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3006 LINCOLNWAY E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MISHAWAKA
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46544-3501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-252-7233
Provider Business Mailing Address Fax Number:
844-361-2090

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3006 LINCOLNWAY E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MISHAWAKA
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46544-3501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-252-7233
Provider Business Practice Location Address Fax Number:
844-361-2090
Provider Enumeration Date:
12/20/2016

Additional Information

Authorized Official

Authorized Official Last Name:
WANG
Authorized Official First Name:
EMMA
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
574-252-7233

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QA0401X , with the licence number: BX2361145 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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