Healthcare Provider Details

I. General information

NPI: 1164528527
Provider Name (Legal Business Name): CENTER FOR DIGESTIVE CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 08/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 ELLIOTT DR
YPSILANTI MI
48197
US

IV. Provider business mailing address

5300 ELLIOTT DR
YPSILANTI MI
48197
US

V. Phone/Fax

Practice location:
  • Phone: 734-434-6262
  • Fax:
Mailing address:
  • Phone: 734-434-6262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number81-6818
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number4704111201
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number4704204265
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number4704118315
License Number StateMI

VIII. Authorized Official

Name: LANA COOPER
Title or Position: ADMINISTRATOR
Credential:
Phone: 734-528-1405