MEDICARE: FORD PCR DRIVE THRU LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1356001598
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORD PCR DRIVE THRU LLC

Provider Business Mailing Address
First Line	:	24517 FORD RD
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48128-1131
Country	:	US
Telephone Number	:	480-262-7993
Fax Number	:

Provider Business Practice Location Address
First Line	:	24517 FORD RD
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48128-1131
Country	:	US
Telephone Number	:	480-262-7993
Fax Number	:

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	MR. ALI HAZIMEH
Credential	:	MD
Telephone Number	:	313-415-1515

Provider Enumeration Date	:	12/29/2021
Last Update Date	:	07/15/2022

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