1598086985 NPI number — MEDICAL MARIJUANNA CERTIFICATION AND FAMILY PRACTICE, PC

Table of content: (NPI 1598086985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598086985 NPI number — MEDICAL MARIJUANNA CERTIFICATION AND FAMILY PRACTICE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL MARIJUANNA CERTIFICATION AND FAMILY PRACTICE, PC
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:
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NPI Number Information

NPI Number:
1598086985
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 CRESCENT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49203-3865
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-960-3634
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1302 N EATON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBION
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49224-1041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-629-3008
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/19/2010

Additional Information

Authorized Official

Authorized Official Last Name:
PIERRE-PAUL
Authorized Official First Name:
JEAN
Authorized Official Middle Name:
ROMMEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
517-960-3634

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  4301090976 , 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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