Provider Demographics
NPI:1306182514
Name:MDL VENTURES OF WEST BLOOMFIELD ACTIVERX
Entity Type:Organization
Organization Name:MDL VENTURES OF WEST BLOOMFIELD ACTIVERX
Other - Org Name:ACTIVERX OF WEST BLOOMFIELD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:LINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-932-0111
Mailing Address - Street 1:6018 W MAPLE RD
Mailing Address - Street 2:SUITE 850
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-4404
Mailing Address - Country:US
Mailing Address - Phone:248-932-0111
Mailing Address - Fax:248-932-0110
Practice Address - Street 1:6018 W MAPLE RD
Practice Address - Street 2:SUITE 850
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-4404
Practice Address - Country:US
Practice Address - Phone:248-932-0111
Practice Address - Fax:248-932-0110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-14
Last Update Date:2012-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty