Basic Information
Provider Information | |||||||||
NPI: | 1922259654 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SSAC, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ARCADIA RX | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 26777 CENTRAL PARK BLVD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | SOUTHFIELD | ||||||||
State: | MI | ||||||||
PostalCode: | 480764162 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8004424579 | ||||||||
FaxNumber: | 8007852177 | ||||||||
Practice Location | |||||||||
Address1: | 3524 PARK PLAZA RD | ||||||||
Address2: |   | ||||||||
City: | PADUCAH | ||||||||
State: | KY | ||||||||
PostalCode: | 420018900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2483527530 | ||||||||
FaxNumber: | 2483525189 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/30/2008 | ||||||||
LastUpdateDate: | 02/25/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SPARLING | ||||||||
AuthorizedOfficialFirstName: | CATHY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2483527530 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ARCADIA PRODUCTS, INC | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | R.N. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | P06890 | KY | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
ID Information
ID | Type | State | Issuer | Description | 90007691 | 05 | KY |   | MEDICAID |