Healthcare Provider Details

I. General information

NPI: 1508672775
Provider Name (Legal Business Name): MUTAHR ALIE MUTAHR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2024
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7940 CREEK BEND
YPSILANTI MI
48197
US

IV. Provider business mailing address

7940 CREEK BEND DR
YPSILANTI MI
48197
US

V. Phone/Fax

Practice location:
  • Phone: 734-846-4187
  • Fax:
Mailing address:
  • Phone: 734-846-4187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number4401001370
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: