1477611978 NPI number — COUNTY OF LUCE

Table of content: (NPI 1477611978)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477611978 NPI number — COUNTY OF LUCE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTY OF LUCE
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:
LUCE COUNTY ADVANCED LIFE SUPPORT SERVICE
Provider Other Organization Name Type Code:
5
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:
1477611978
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2122
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERVIEW
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48193-1122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-479-6300
Provider Business Mailing Address Fax Number:
734-479-6319

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
910 WASHINGTON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWBERRY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49868-1713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-293-8871
Provider Business Practice Location Address Fax Number:
906-293-8536
Provider Enumeration Date:
12/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SMITHSON
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
Authorized Official Title or Position:
EMS DIRECTOR
Authorized Official Telephone Number:
906-293-8871

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  481001 , 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: OD80002 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 3002635 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10571 . This is a "GREAT LAKES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 690350436 . This is a "STATE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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