Provider Demographics
NPI:1093061137
Name:ED ROSS LC
Entity Type:Organization
Organization Name:ED ROSS LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:AL
Authorized Official - Middle Name:
Authorized Official - Last Name:TACKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-419-0135
Mailing Address - Street 1:PO BOX 263
Mailing Address - Street 2:
Mailing Address - City:ALBION
Mailing Address - State:MI
Mailing Address - Zip Code:49224-0263
Mailing Address - Country:US
Mailing Address - Phone:517-629-4178
Mailing Address - Fax:
Practice Address - Street 1:25880 HILL RD
Practice Address - Street 2:
Practice Address - City:ALBION
Practice Address - State:MI
Practice Address - Zip Code:49224-9711
Practice Address - Country:US
Practice Address - Phone:517-629-4178
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-26
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health