Provider Demographics
NPI:1114290517
Name:139 EDUCATION, LLC
Entity Type:Organization
Organization Name:139 EDUCATION, LLC
Other - Org Name:NEUROCORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-706-5649
Mailing Address - Street 1:3790 30TH ST SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1602
Mailing Address - Country:US
Mailing Address - Phone:800-600-4096
Mailing Address - Fax:800-606-8839
Practice Address - Street 1:1971 E BELTLINE AVE NE
Practice Address - Street 2:SUITE 212
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-7045
Practice Address - Country:US
Practice Address - Phone:800-600-4096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009353103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1013294628OtherNPI #
MI0D14689OtherBLUE CROSS BLUE SHIELD OF MICHIGAN