=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144354820
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHORELINE ENT PLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2007
-----------------------------------------------------
Last Update Date | 07/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 268 SEMINOLE RD
-----------------------------------------------------
City | MUSKEGON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49444-3733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-777-2625
-----------------------------------------------------
Fax | 231-773-8560
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 268 SEMINOLE RD
-----------------------------------------------------
City | MUSKEGON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49444-3733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-777-2625
-----------------------------------------------------
Fax | 231-773-8560
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | NICHOLE GOODCHILD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 231-777-2625
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207YX0007X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery within the Head & Neck (Otolaryngology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------