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General NPI Number Information
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NPI Number | 1538481072
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Entity Type | Organization
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Legal Business Name | SUNDARA NPHC
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Dates
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Enumeration Date | 02/25/2010
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Last Update Date | 02/25/2010
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Provider Practice Location Address
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Address Line | 410 LINCOLN AVE
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City | MARQUETTE
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State | MI
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Zip | 49855
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Country | US
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Telephone | 906-225-0848
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Fax | 906-228-2050
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Provider Business Mailing Address
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Address Line | 410 LINCOLN AVE
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City | MARQUETTE
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State | MI
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Zip | 49855
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Country | US
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Telephone | 906-225-0848
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Fax | 906-228-2050
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Authorized Official
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Title or Position | OPERATIONS MANAGER
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Name | MS. CHRISTINE SUSAN MARTIN
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Credential |
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Telephone | 906-225-0848
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | AL520007247
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License Number State | MI
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