Provider Demographics
NPI:1124393202
Name:IMAN NP CENTER LLC
Entity Type:Organization
Organization Name:IMAN NP CENTER LLC
Other - Org Name:IMAN NURSE PRACTITIONER CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIVACHI-WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:248-595-8536
Mailing Address - Street 1:26771 W 12 MILE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1539
Mailing Address - Country:US
Mailing Address - Phone:248-595-8536
Mailing Address - Fax:248-809-2043
Practice Address - Street 1:26771 W 12 MILE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1539
Practice Address - Country:US
Practice Address - Phone:248-595-8536
Practice Address - Fax:248-809-2043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-21
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261Q00000X
363LA2200X, 363LP0200X, 363LP2300X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5008616330OtherBCBS/BCN