Healthcare Provider Details

I. General information

NPI: 1326587114
Provider Name (Legal Business Name): MED SPORTS VANTAGE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2017
Last Update Date: 10/10/2026
Certification Date: 10/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S EAST ST STE 2
BRIGHTON MI
48116-1592
US

IV. Provider business mailing address

210 S EAST ST STE 2
BRIGHTON MI
48116-1592
US

V. Phone/Fax

Practice location:
  • Phone: 810-626-3036
  • Fax: 810-202-1130
Mailing address:
  • Phone: 810-626-3036
  • Fax: 810-202-1130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number5601003608
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601003608
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number5601003608
License Number StateMI

VIII. Authorized Official

Name: RACHEL LETHORN
Title or Position: CEO / OWNER
Credential: PA-C
Phone: 810-626-3036