=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083996102
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WINCHESTER SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2011
-----------------------------------------------------
Last Update Date | 09/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18470 SANTA ANN AVE.
-----------------------------------------------------
City | LATHRUP VILLAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48076-4525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-477-3055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18470 SANTA ANN AVE
-----------------------------------------------------
City | LATHRUP VILLAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48076-4525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-477-3055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | IRIS LENA WINCHESTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-477-3055
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2081P2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------