1982700779 NPI number — MEDICINE ROOM

Table of content: (NPI 1982700779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982700779 NPI number — MEDICINE ROOM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICINE ROOM
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:
1982700779
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
72 S. WASHINGTON ST STE 207 OXFORD, MI 48371
Provider Second Line Business Mailing Address:
STE 207
Provider Business Mailing Address City Name:
OXFORD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48371
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-628-7990
Provider Business Mailing Address Fax Number:
248-628-6507

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
72 S. WASHINGTON ST
Provider Second Line Business Practice Location Address:
STE 207
Provider Business Practice Location Address City Name:
OXFORD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-628-7990
Provider Business Practice Location Address Fax Number:
248-628-6507
Provider Enumeration Date:
09/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CRISP
Authorized Official First Name:
THERESA
Authorized Official Middle Name:
Authorized Official Title or Position:
RPH,OWNER
Authorized Official Telephone Number:
810-441-1685

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  5301003591 , 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: 2102167 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com