1922070929 NPI number — LTC LEONARD LLC

Table of content: (NPI 1922070929)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922070929 NPI number — LTC LEONARD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LTC LEONARD 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:
1922070929
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2233 TRACY RD STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTHWOOD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43619-1302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-764-0400
Provider Business Mailing Address Fax Number:
517-764-0475

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4646 PAGE AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MICHIGAN CENTER
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49254-1042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-764-0400
Provider Business Practice Location Address Fax Number:
517-764-0475
Provider Enumeration Date:
02/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SCHOEN
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
419-654-1973

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  5301000646 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 5301000646 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 5301000646 , 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: 2307254 . This is a "NCPDP/NABP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 872503134 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 540C805637 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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