1568998003 NPI number — VICTORIA LYNN FAIRLEY-GREEN COTAL

Table of content: VICTORIA LYNN FAIRLEY-GREEN COTAL (NPI 1568998003)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568998003 NPI number — VICTORIA LYNN FAIRLEY-GREEN COTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAIRLEY-GREEN
Provider First Name:
VICTORIA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
COTAL
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:
1568998003
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29221 MARK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON HEIGHTS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48071-4469
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-677-4174
Provider Business Mailing Address Fax Number:
248-677-4174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17177 N LAUREL PARK DR STE 417
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIVONIA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48152-3952
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-666-5995
Provider Business Practice Location Address Fax Number:
877-414-9925
Provider Enumeration Date:
05/03/2017

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: 224Z00000X , with the licence number:  5202007270 , 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)





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