Healthcare Provider Details

I. General information

NPI: 1346918463
Provider Name (Legal Business Name): ELLEN GURECKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2021
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 LAURENCE AVE
JACKSON MI
49202-2979
US

IV. Provider business mailing address

2365 HOWELL RD
WILLIAMSTON MI
48895-9686
US

V. Phone/Fax

Practice location:
  • Phone: 517-750-4777
  • Fax:
Mailing address:
  • Phone: 517-749-3983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: