=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295563559
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOTOR CITY DRIP L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2024
-----------------------------------------------------
Last Update Date | 10/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20110 FORT ST APT 201
-----------------------------------------------------
City | RIVERVIEW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48193-8721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-772-8352
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20110 FORT ST APT 201
-----------------------------------------------------
City | RIVERVIEW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48193-8721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-772-8352
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/C.E.O.
-----------------------------------------------------
Name | MISS STAR BILLY SCHUMAKE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 734-772-8352
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------