Healthcare Provider Details

I. General information

NPI: 1255422010
Provider Name (Legal Business Name): HARBOR OXYGEN OF SOUTHEAST MI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29454 HAAS RD
WIXOM MI
48393-3022
US

IV. Provider business mailing address

29454 HAAS RD
WIXOM MI
48393-3022
US

V. Phone/Fax

Practice location:
  • Phone: 248-446-6114
  • Fax: 248-446-6115
Mailing address:
  • Phone: 248-446-6114
  • Fax: 248-446-6115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: SHANNON BURRELL
Title or Position: PRESIDENT
Credential:
Phone: 248-446-6114