Healthcare Provider Details

I. General information

NPI: 1609409929
Provider Name (Legal Business Name): FIRESTONE PROCEDURE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2020
Last Update Date: 02/14/2020
Certification Date: 02/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4520 FIRESTONE ST STE C
DEARBORN MI
48126-4602
US

IV. Provider business mailing address

4520 FIRESTONE ST STE C
DEARBORN MI
48126-4602
US

V. Phone/Fax

Practice location:
  • Phone: 313-528-1145
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MOHAMED TANANA
Title or Position: OWNER
Credential:
Phone: 313-641-2222