Basic Information
Provider Information | |||||||||
NPI: | 1184018210 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WESTERN WAYNE FAMILY HEALTH CENTERS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WESTERN WAYNE FAMILY HEALTH CENTERS-TAYLOR | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 26650 EUREKA RD | ||||||||
Address2: | SUITE C-1 | ||||||||
City: | TAYLOR | ||||||||
State: | MI | ||||||||
PostalCode: | 481804835 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7349414991 | ||||||||
FaxNumber: | 7349414919 | ||||||||
Practice Location | |||||||||
Address1: | 26650 EUREKA RD | ||||||||
Address2: | SUITE C-1 | ||||||||
City: | TAYLOR | ||||||||
State: | MI | ||||||||
PostalCode: | 481804835 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7349414991 | ||||||||
FaxNumber: | 7349414919 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/26/2015 | ||||||||
LastUpdateDate: | 03/26/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ATKINS | ||||||||
AuthorizedOfficialFirstName: | LINDA | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 7349414991 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | WESTERN WAYNE FAMILY HEALTH CENTERS | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | RN | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.