Healthcare Provider Details

I. General information

NPI: 1790365807
Provider Name (Legal Business Name): MRS. SUE CIOCHON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2021
Last Update Date: 04/12/2021
Certification Date: 04/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6460 BROOKVILLE RD
SOUTH LYON MI
48178-7004
US

IV. Provider business mailing address

6460 BROOKVILLE RD
SOUTH LYON MI
48178-7004
US

V. Phone/Fax

Practice location:
  • Phone: 734-660-9981
  • Fax:
Mailing address:
  • Phone: 734-660-9981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2278C0205X
TaxonomyCritical Care Certified Respiratory Therapist
License Number4401003554
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: