Healthcare Provider Details

I. General information

NPI: 1649658915
Provider Name (Legal Business Name): LAKES URGENT CARE-ST JOSEPH LIVONIA CAMPUS-PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2015
Last Update Date: 07/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36622 FIVE MILE RD
LIVONIA MI
48154-1900
US

IV. Provider business mailing address

2300 HAGGERTY RD SUITE 1010
WEST BLOOMFIELD MI
48323-2184
US

V. Phone/Fax

Practice location:
  • Phone: 248-926-9111
  • Fax: 248-926-9112
Mailing address:
  • Phone: 248-926-9111
  • Fax: 248-926-9112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number5101010234
License Number StateMI

VIII. Authorized Official

Name: DR. SANFORD J VIEDER
Title or Position: MEDICAL DIRECTOR
Credential: D.O.
Phone: 248-931-2274