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General NPI Number Information
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NPI Number | 1225371495
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Entity Type | Organization
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Legal Business Name | SUPERIOR LOVE
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Dates
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Enumeration Date | 04/05/2013
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Last Update Date | 04/05/2013
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Provider Practice Location Address
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Address Line | 4205 PENGELLY RD
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City | FLINT
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State | MI
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Zip | 48507-5430
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Country | US
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Telephone | 810-288-1155
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Fax |
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Provider Business Mailing Address
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Address Line | 609 E BALTIMORE BLVD
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City | FLINT
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State | MI
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Zip | 48505-6404
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Country | US
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Telephone | 810-423-0857
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Fax |
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Authorized Official
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Title or Position | VICE- PRESIDENT
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Name | MRS. CHRISTINA THOMPSON
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Credential |
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Telephone | 810-288-1155
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number | 1013271923
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License Number State | MI
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