=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770837296
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHIGAN HOME EXTERIORS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2012
-----------------------------------------------------
Last Update Date | 11/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11444 KALTZ AVE
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48089
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-256-5393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11444 KALTZ AVE
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48089-1867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-256-5393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. JOSEPH DANIEL RADLICK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 855-789-2284
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 2101170519
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------