1740343623 NPI number — TRI-STARS INC

Table of content: (NPI 1740343623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740343623 NPI number — TRI-STARS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI-STARS INC
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:
1740343623
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
828 SHERIDAN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ESCANABA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49829-1531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-786-2051
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9425 00.25 RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COOKS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49817-9607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-644-2488
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MANSON
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING AGENT
Authorized Official Telephone Number:
906-786-2051

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  211001 , 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: 4365547 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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