Provider Demographics
NPI:1922695303
Name:JOHN EID SOLE MBR
Entity Type:Organization
Organization Name:JOHN EID SOLE MBR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:EID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-907-1092
Mailing Address - Street 1:APPLEWOOND DR SHELBY
Mailing Address - Street 2:
Mailing Address - City:BROOKS
Mailing Address - State:MI
Mailing Address - Zip Code:53912
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:APPLEWOOND DR SHELBY
Practice Address - Street 2:
Practice Address - City:BROOKS
Practice Address - State:MI
Practice Address - Zip Code:53912
Practice Address - Country:US
Practice Address - Phone:586-907-1092
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-31
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE200429772052Medicaid