Provider Demographics
NPI:1184972465
Name:RONALD J FLACK LLC
Entity type:Organization
Organization Name:RONALD J FLACK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:ETUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-522-8582
Mailing Address - Street 1:762 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1978
Mailing Address - Country:US
Mailing Address - Phone:517-782-8142
Mailing Address - Fax:517-782-0765
Practice Address - Street 1:762 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1978
Practice Address - Country:US
Practice Address - Phone:517-782-8142
Practice Address - Fax:517-782-0765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-17
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704149271363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty