Provider Demographics
NPI:1154939106
Name:MIRABITUR, MADISON LOVE I
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:LOVE
Last Name:MIRABITUR
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25900 GREENFIELD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-1297
Mailing Address - Country:US
Mailing Address - Phone:248-788-4300
Mailing Address - Fax:
Practice Address - Street 1:25900 GREENFIELD RD STE 100
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-1297
Practice Address - Country:US
Practice Address - Phone:248-788-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-15
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501303543225100000X
3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant