Healthcare Provider Details

I. General information

NPI: 1255182671
Provider Name (Legal Business Name): ANDREA ROSE TOMES HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANDREA ROSE PECNIK

II. Dates (important events)

Enumeration Date: 04/01/2024
Last Update Date: 04/01/2024
Certification Date: 04/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 N JEBAVY DR
LUDINGTON MI
49431-1923
US

IV. Provider business mailing address

325 N JEBAVY DR
LUDINGTON MI
49431-1923
US

V. Phone/Fax

Practice location:
  • Phone: 231-843-7019
  • Fax:
Mailing address:
  • Phone: 231-843-7019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number350201277
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: