=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144500406
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2011
-----------------------------------------------------
Last Update Date | 08/18/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12947 TOWNSEND DR #412
-----------------------------------------------------
City | GRAND LEDGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48837-8727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-901-3098
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12947 TOWNSEND DR #412
-----------------------------------------------------
City | GRAND LEDGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48837-8727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-901-3098
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | BLANCHE R ROSENBLATT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-901-3098
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2301009814
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------