=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871108217
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACADIAN SUPREME HEALTH SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2020
-----------------------------------------------------
Last Update Date | 09/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12866 FORT ST
-----------------------------------------------------
City | SOUTHGATE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48195-1060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-930-0258
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20831 RIDGEMONT RD
-----------------------------------------------------
City | HARPER WOODS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48225-1137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-930-0258
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL/FNP
-----------------------------------------------------
Name | INGRID N. LEWIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-930-0258
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------