Provider Demographics
NPI:1306172739
Name:CEDARVILLE COMMONS, INC.
Entity type:Organization
Organization Name:CEDARVILLE COMMONS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:NOBEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-484-1001
Mailing Address - Street 1:266 MARY L STREET
Mailing Address - Street 2:
Mailing Address - City:CEDARVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49719
Mailing Address - Country:US
Mailing Address - Phone:906-484-1001
Mailing Address - Fax:
Practice Address - Street 1:266 MARY L STREET
Practice Address - Street 2:
Practice Address - City:CEDARVILLE
Practice Address - State:MI
Practice Address - Zip Code:49719
Practice Address - Country:US
Practice Address - Phone:906-484-1001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI23D1075173291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory