1467216994 NPI number — MRS. JOSIE LYNN CHARLES TLLP

Table of content: MRS. JOSIE LYNN CHARLES TLLP (NPI 1467216994)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467216994 NPI number — MRS. JOSIE LYNN CHARLES TLLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHARLES
Provider First Name:
JOSIE
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
TLLP
Provider Gender Code:
F

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:
1467216994
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7159 MELDRUM RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48023-2429
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-804-1207
Provider Business Mailing Address Fax Number:
586-286-5834

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8344 HALL RD STE 209
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UTICA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48317-5554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-286-5870
Provider Business Practice Location Address Fax Number:
586-286-5834
Provider Enumeration Date:
02/06/2024

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: 103T00000X , with the licence number:  636200902 , 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: 636200902 . This is a "STATE LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".