Provider Demographics
NPI:1629281068
Name:BIOLIGHT THERAPEUTICS LLC
Entity Type:Organization
Organization Name:BIOLIGHT THERAPEUTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-456-0619
Mailing Address - Street 1:15600 W 7 MILE RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-2928
Mailing Address - Country:US
Mailing Address - Phone:248-456-0619
Mailing Address - Fax:248-456-0729
Practice Address - Street 1:15600 W 7 MILE RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2928
Practice Address - Country:US
Practice Address - Phone:248-456-0619
Practice Address - Fax:248-456-0729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301034892173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F32887OtherBCBS OF MI
MI0F32887OtherBCBS OF MI