Healthcare Provider Details

I. General information

NPI: 1922125400
Provider Name (Legal Business Name): ALONZO FULTON HOVER CAC1
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13340 E WARREN AVE
DETROIT MI
48215-2112
US

IV. Provider business mailing address

13340 E WARREN AVE
DETROIT MI
48215-2112
US

V. Phone/Fax

Practice location:
  • Phone: 313-822-6940
  • Fax: 313-822-6946
Mailing address:
  • Phone: 313-822-6940
  • Fax: 313-822-6946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: