MEDICARE: MAVERICK ONE INC

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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1578195889
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAVERICK ONE INC

Provider Business Mailing Address
First Line	:	900 LINCOLN LN APT 802
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48126-2987
Country	:	US
Telephone Number	:	313-283-3722
Fax Number	:

Provider Business Practice Location Address
First Line	:	900 LINCOLN LN APT 802
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48126-2987
Country	:	US
Telephone Number	:	313-283-3722
Fax Number	:	313-914-3094

Authorized Official
Title or Position	:	OWNER
Name	:	LAWANDA JEAN GREGORY
Credential	:
Telephone Number	:	313-283-3722

Provider Enumeration Date	:	02/05/2020
Last Update Date	:	02/05/2020

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Directions to “MAVERICK ONE INC ” Practice Location

Language	Start Address	Practice Location

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