Provider Demographics
NPI:1922003664
Name:HARBOR OXYGEN OF TRAVERSE CITY, LLC
Entity Type:Organization
Organization Name:HARBOR OXYGEN OF TRAVERSE CITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:MAYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-946-0550
Mailing Address - Street 1:3860 N LONG LAKE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7204
Mailing Address - Country:US
Mailing Address - Phone:231-946-0550
Mailing Address - Fax:231-946-0559
Practice Address - Street 1:3860 N LONG LAKE RD STE 1
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7204
Practice Address - Country:US
Practice Address - Phone:231-946-0550
Practice Address - Fax:231-946-0559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-18
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540B810880OtherBC/BS OF MICHIGAN
MI874535440Medicaid
MI874535440Medicaid
MI4866470001Medicare NSC