Provider Demographics
NPI:1215988845
Name:RISING STAR WELLNESS CENTER PLC
Entity type:Organization
Organization Name:RISING STAR WELLNESS CENTER PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FLORA
Authorized Official - Middle Name:ERMENIA
Authorized Official - Last Name:BIANCALANA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-932-1988
Mailing Address - Street 1:3189 LOGAN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-4772
Mailing Address - Country:US
Mailing Address - Phone:231-932-1988
Mailing Address - Fax:
Practice Address - Street 1:3189 LOGAN VALLEY RD
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-4772
Practice Address - Country:US
Practice Address - Phone:231-932-1988
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4291443 10Medicaid
MIH36352Medicare UPIN
MI4291443 10Medicaid
MI0N28290Medicare PIN