Basic Information
| Provider Information | |||||||||
| NPI: | 1740726546 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KEYSTONE INFUSION LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2517 BENTLEY CT | ||||||||
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| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488232972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173391676 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6200 PINE HOLLOW DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488239224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173391676 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2017 | ||||||||
| LastUpdateDate: | 01/17/2017 | ||||||||
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| AuthorizedOfficialLastName: | TITLE | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4197087378 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.