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General NPI Number Information
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NPI Number | 1629456959
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Entity Type | Individual
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Provider Name | ELIA MTIMAVALYE
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Gender | Male
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Dates
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Enumeration Date | 05/06/2015
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Last Update Date | 05/06/2015
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Provider Practice Location Address
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Address Line | 910 PIERCE RD
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City | LANSING
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State | MI
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Zip | 48910-5274
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Country | US
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Telephone | 517-410-7313
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Fax |
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Provider Business Mailing Address
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Address Line | 910 PIERCE RD
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City | LANSING
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State | MI
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Zip | 48910-5274
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Country | US
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Telephone | 517-410-7313
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253J00000X
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Taxonomy Name | Foster Care Agency
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License Number | AF330334043
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License Number State | MI
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