Healthcare Provider Details

I. General information

NPI: 1265747877
Provider Name (Legal Business Name): MCKINLEY WILLIAMS MANAGER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2010
Last Update Date: 08/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3428 S. TOWER LINE
BRIDGEPORT MI
48722-9542
US

IV. Provider business mailing address

3428 S. TOWER LINE RD
BRIDGEPORT MI
48722-9542
US

V. Phone/Fax

Practice location:
  • Phone: 989-777-5561
  • Fax: 989-777-7326
Mailing address:
  • Phone: 989-777-5561
  • Fax: 989-777-7326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License NumberAS730296526
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: