Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156F00000X | Technician/Technologist |
NPI | 1164996260 |
---|---|
Provider Name | John Stathakios |
First Address | Bingham Farms, MI 48025-2454 |
Second Address | Bingham Farms, MI 48025-2454 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/01/2019 |
Last Update Date | 11/01/2019 |