Provider Demographics
NPI:1679072763
Name:FENTON LATE HOURS CLINIC II PC
Entity Type:Organization
Organization Name:FENTON LATE HOURS CLINIC II PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:DURMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-629-7511
Mailing Address - Street 1:102 N ADELAIDE ST
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-2670
Mailing Address - Country:US
Mailing Address - Phone:810-629-7511
Mailing Address - Fax:810-629-6535
Practice Address - Street 1:102 N ADELAIDE ST
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-2670
Practice Address - Country:US
Practice Address - Phone:810-629-7511
Practice Address - Fax:810-629-6535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care