Healthcare Provider Details

I. General information

NPI: 1174976740
Provider Name (Legal Business Name): NICOLE SAPIRO VINCKIER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2016
Last Update Date: 07/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35046 WOODWARD AVE STE 100
BIRMINGHAM MI
48009-0964
US

IV. Provider business mailing address

1307 WEBSTER ST
BIRMINGHAM MI
48009-7090
US

V. Phone/Fax

Practice location:
  • Phone: 248-647-9860
  • Fax: 248-647-9864
Mailing address:
  • Phone: 818-726-3262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601007743
License Number StateMI

VIII. Authorized Official

Name: MR. JOHN R SANBORN
Title or Position: CO-OWNER AUTHORIZED OFFICIAL
Credential: M.D.
Phone: 248-647-9860