=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649642505
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUPERIOR VISIONS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2015
-----------------------------------------------------
Last Update Date | 10/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2709 FORT STREET
-----------------------------------------------------
City | WYANDOTTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-250-9445
-----------------------------------------------------
Fax | 734-556-3280
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2709 FORT STREET
-----------------------------------------------------
City | WYANDOTTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-250-9445
-----------------------------------------------------
Fax | 734-556-3280
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TANGANYIKA WILKERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-404-8231
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------