Provider Demographics
NPI:1609229335
Name:VAILU, JEFF
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:VAILU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28880 APPLE BLOOSM DRIVE
Mailing Address - Street 2:
Mailing Address - City:FLAT ROCK
Mailing Address - State:MI
Mailing Address - Zip Code:48134-3151
Mailing Address - Country:US
Mailing Address - Phone:734-782-5932
Mailing Address - Fax:
Practice Address - Street 1:28880 APPLEBLOSSOM DRIVE
Practice Address - Street 2:
Practice Address - City:FLAT ROCK
Practice Address - State:MI
Practice Address - Zip Code:48134-3151
Practice Address - Country:US
Practice Address - Phone:734-642-5932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703108476164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse