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General NPI Number Information
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NPI Number | 1316145972
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Entity Type | Organization
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Legal Business Name | ADVANTAGE HEALTH CLINIC, FOR MEN, INC
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Dates
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Enumeration Date | 07/05/2007
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Last Update Date | 05/29/2009
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Provider Practice Location Address
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Address Line | 18625 CENTENNIAL RD SUITE D
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City | MARSHALL
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State | MI
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Zip | 49068-9372
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Country | US
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Telephone | 269-789-1900
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Fax | 269-789-1974
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Provider Business Mailing Address
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Address Line | 18625 CENTENNIAL RD SUITE D
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City | MARSHALL
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State | MI
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Zip | 49068-9372
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Country | US
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Telephone | 269-789-1900
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Fax | 269-789-1974
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Authorized Official
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Title or Position | MANAGER
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Name | MRS. LISA A IGNATOSKI
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Credential |
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Telephone | 269-789-1900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0505X
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Taxonomy Name | Adult Medicine Physician
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License Number | 4301033625
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License Number State | MI
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