1609076421 NPI number — GRAND BLANC SPINE CENTER

Table of content: (NPI 1609076421)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609076421 NPI number — GRAND BLANC SPINE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND BLANC SPINE CENTER
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:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609076421
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
11/27/2012
NPI Reactivation Date:
12/10/2014

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10683 S SAGINAW ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
GRAND BLANC
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48439-8127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-694-3576
Provider Business Mailing Address Fax Number:
810-694-9544

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10683 S SAGINAW ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
GRAND BLANC
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48439-8127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-694-3576
Provider Business Practice Location Address Fax Number:
810-694-9544
Provider Enumeration Date:
07/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MORNINGSTAR
Authorized Official First Name:
MARK
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
810-694-3576

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  MM008587 , 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: 4446888 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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