Provider Demographics
NPI:1942747423
Name:MY TACTICAL ADVANTAGE LLC
Entity type:Organization
Organization Name:MY TACTICAL ADVANTAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TAREEQ
Authorized Official - Middle Name:
Authorized Official - Last Name:ELMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-544-8229
Mailing Address - Street 1:13305 W 7 MILE RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-1340
Mailing Address - Country:US
Mailing Address - Phone:313-544-8229
Mailing Address - Fax:
Practice Address - Street 1:13305 W 7 MILE RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-1340
Practice Address - Country:US
Practice Address - Phone:313-544-8229
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)