=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124548185
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VERDUROUS ME, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2017
-----------------------------------------------------
Last Update Date | 06/22/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 49881 GRAND RIVER AVE
-----------------------------------------------------
City | WIXOM
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48393-3309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-229-4016
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25645 INGLESIDE DR
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48033-4844
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LEESA HANKSNECHT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-420-7439
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174H00000X
-----------------------------------------------------
Taxonomy Name | Health Educator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 175L00000X
-----------------------------------------------------
Taxonomy Name | Homeopath
-----------------------------------------------------
License Number | 68663511
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 18966MIPFT
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 7501010100
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------