=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225562150
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANA LANGE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2017
-----------------------------------------------------
Last Update Date | 04/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 41521 W 11 MILE RD
-----------------------------------------------------
City | NOVI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48375-1803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-299-0030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 54305 BLUE CLOUD DR
-----------------------------------------------------
City | SHELBY TOWNSHIP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48315-1227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-337-0521
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 247200000X
-----------------------------------------------------
Taxonomy Name | Other Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------