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General NPI Number Information
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NPI Number | 1326587114
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Entity Type | Organization
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Legal Business Name | MED SPORTS VANTAGE PLLC
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Dates
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Enumeration Date | 02/14/2017
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Last Update Date | 03/25/2023
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Provider Practice Location Address
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Address Line | 210 S EAST ST STE 2
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City | BRIGHTON
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State | MI
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Zip | 48116-1592
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Country | US
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Telephone | 810-626-3036
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Fax | 810-202-1130
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Provider Business Mailing Address
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Address Line | 210 S EAST ST STE 2
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City | BRIGHTON
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State | MI
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Zip | 48116-1592
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Country | US
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Telephone | 810-626-3036
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Fax | 810-202-1130
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Authorized Official
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Title or Position | CEO / OWNER
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Name | RACHEL LETHORN
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Credential | PA-C
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Telephone | 810-626-3036
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RA0401X
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Taxonomy Name | Addiction Medicine (Internal Medicine) Physician
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License Number | 5601003608
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 5601003608
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 5601003608
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License Number State | MI
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Taxonomy #4
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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