| Organization Name: | SIXTY FOURTH STREET LLC |
| NPI Number: | 1164538286 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | GREGORY JOHNSON (MEDICAL DIRECTOR) |
| Mailing Address: | 2373 64th St Sw Suite 2200 Byron Center |
| State: | MI US |
| Postal Code: | 493157974 |
| Phone Number: | 6166853975 |
| Fax Number: | 6166853977 |
| NPI Enumeration Date: | 08/22/2006 |
| NPI Last Update Date: | 07/17/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QA1903X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Ambulatory Surgical |
| Taxonomy Definition: | |