1497196703 NPI number — ST CLAIR OPCO LLC

Table of content: (NPI 1497196703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497196703 NPI number — ST CLAIR OPCO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST CLAIR OPCO 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:
6
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:
1497196703
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7400 NEW LA GRANGE RD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40222-4870
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-429-8062
Provider Business Mailing Address Fax Number:
502-429-0650

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4220 HOSPITAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST CHINA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48054-2200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-329-4736
Provider Business Practice Location Address Fax Number:
810-329-6282
Provider Enumeration Date:
07/15/2013

Additional Information

Authorized Official

Authorized Official Last Name:
ROGERS
Authorized Official First Name:
STACEY
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
502-429-8062

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1497196703 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com