Healthcare Provider Details

I. General information

NPI: 1750826236
Provider Name (Legal Business Name): MAINSTREAM MEDIA GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2016
Last Update Date: 12/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 TOWN CTR 2405
SOUTHFIELD MI
48075-1110
US

IV. Provider business mailing address

5000 TOWN CTR 2405
SOUTHFIELD MI
48075-1110
US

V. Phone/Fax

Practice location:
  • Phone: 248-943-4107
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: GABRIELLE THRASHER
Title or Position: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 248-943-4107