=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457815565
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ISIDRO II INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2019
-----------------------------------------------------
Last Update Date | 06/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7288 N SHELDON RD STE A
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48187-2150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-812-9129
-----------------------------------------------------
Fax | 734-629-1717
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 871819
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48187-7519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-812-9129
-----------------------------------------------------
Fax | 734-629-1717
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARIA CHRISTINA YOUNG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 734-812-9129
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174H00000X
-----------------------------------------------------
Taxonomy Name | Health Educator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------