Healthcare Provider Details

I. General information

NPI: 1720072812
Provider Name (Legal Business Name): PROFESSIONAL HOME CARE DEARBORN OXYGEN THERAPY CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 01/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24706 MICHIGAN AVE
DEARBORN MI
48124-1750
US

IV. Provider business mailing address

24706 MICHIGAN AVE
DEARBORN MI
48124-1750
US

V. Phone/Fax

Practice location:
  • Phone: 313-277-2160
  • Fax: 313-277-3079
Mailing address:
  • Phone: 313-277-2160
  • Fax: 313-277-3079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332100000X
TaxonomyDepartment of Veterans Affairs (VA) Pharmacy
License Number5306000370
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. BRIAN G KOLFAGE
Title or Position: PRESIDENT
Credential:
Phone: 313-277-2160