1942249818 NPI number — HEARTLAND-DORVIN OF LIVONIA MI LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942249818 NPI number — HEARTLAND-DORVIN OF LIVONIA MI LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEARTLAND-DORVIN OF LIVONIA MI 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:
HEARTLAND HEALTH CARE CENTER-LIVONIA NE
Provider Other Organization Name Type Code:
3
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:
1942249818
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
333 N SUMMIT ST
Provider Second Line Business Mailing Address:
ATTN: BARRY LAZARUS
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43604-1531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-252-5541
Provider Business Mailing Address Fax Number:
419-252-5548

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
29270 MORLOCK ST
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:
48152-2044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-476-0555
Provider Business Practice Location Address Fax Number:
248-477-5391
Provider Enumeration Date:
06/06/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LAZARUS
Authorized Official First Name:
BARRY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
VICE PRESIDENT - REIMBURSEMENTS
Authorized Official Telephone Number:
419-252-5541

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  824110 , 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: 605290914 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".