Provider Demographics
NPI:1497587679
Name:80TH STREET CORPORATION
Entity type:Organization
Organization Name:80TH STREET CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARLY
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-309-9657
Mailing Address - Street 1:525 AVIS DR STE 3
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-9616
Mailing Address - Country:US
Mailing Address - Phone:734-622-8190
Mailing Address - Fax:
Practice Address - Street 1:525 AVIS DR STE 3
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-9616
Practice Address - Country:US
Practice Address - Phone:734-622-8190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care