=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689941783
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDRE LATELY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2011
-----------------------------------------------------
Last Update Date | 11/18/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27003 PLYMOUTH RD
-----------------------------------------------------
City | REDFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48239-2343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-744-7055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4388
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48204-0388
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-516-5536
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------