Basic Information
| Provider Information | |||||||||
| NPI: | 1972942423 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMON GROUND SANTUARY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1410 S TELEGRAPH RD | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483020046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484568150 | ||||||||
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| Practice Location | |||||||||
| Address1: | 461 W HURON ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483411601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484561991 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2013 | ||||||||
| LastUpdateDate: | 06/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | SHREVE | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | TANYA-JACKNOW | ||||||||
| AuthorizedOfficialTitleorPosition: | STAFF NURSE | ||||||||
| AuthorizedOfficialTelephone: | 2484568150 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | R.N, | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251J00000X | 4704150668 | MI | Y | Agencies | Nursing Care |
No ID Information.