Healthcare Provider Details

I. General information

NPI: 1114195492
Provider Name (Legal Business Name): JAMES DARRYL PARKS FAODP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2008
Last Update Date: 02/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9605 GRAND RIVER AVE
DETROIT MI
48204-2139
US

IV. Provider business mailing address

9605 GRAND RIVER AVE.
DETROIT MI
48204
US

V. Phone/Fax

Practice location:
  • Phone: 313-834-5930
  • Fax: 313-834-4541
Mailing address:
  • Phone: 313-834-5930
  • Fax: 313-834-4541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number820198
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: