Healthcare Provider Details

I. General information

NPI: 1801734249
Provider Name (Legal Business Name): PANAGIA MEDICAL RECOVERY CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43191 DALCOMA DR STE 101
CLINTON TOWNSHIP MI
48038-6308
US

IV. Provider business mailing address

43191 DALCOMA DR STE 101
CLINTON TOWNSHIP MI
48038-6308
US

V. Phone/Fax

Practice location:
  • Phone: 248-810-4727
  • Fax: 248-810-4727
Mailing address:
  • Phone: 248-810-4727
  • Fax: 248-810-4727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MIRA GRACE
Title or Position: MEMBER
Credential: MD
Phone: 248-810-4727