Healthcare Provider Details

I. General information

NPI: 1912290834
Provider Name (Legal Business Name): LISA THACKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2011
Last Update Date: 05/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 MILITARY ST
PORT HURON MI
48060-5416
US

IV. Provider business mailing address

1953 EMERSON RD
WALES MI
48027-2120
US

V. Phone/Fax

Practice location:
  • Phone: 810-985-5437
  • Fax: 800-248-1568
Mailing address:
  • Phone: 586-484-6657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: