Provider Demographics
NPI:1326587114
Name:MED SPORTS VANTAGE PLLC
Entity Type:Organization
Organization Name:MED SPORTS VANTAGE PLLC
Other - Org Name:MED SPORTS VANTAGE PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LETHORN
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:810-626-3036
Mailing Address - Street 1:210 S EAST ST STE 2
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-1592
Mailing Address - Country:US
Mailing Address - Phone:810-626-3036
Mailing Address - Fax:810-202-1130
Practice Address - Street 1:210 S EAST ST STE 2
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-1592
Practice Address - Country:US
Practice Address - Phone:810-626-3036
Practice Address - Fax:810-202-1130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-14
Last Update Date:2023-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003608207RA0401X, 261QM2500X, 363A00000X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty