Healthcare Provider Details

I. General information

NPI: 1093908436
Provider Name (Legal Business Name): KAMITKO COLEMAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2007
Last Update Date: 09/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16200 BURGESS
DETROIT MI
48219-4804
US

IV. Provider business mailing address

16200 BURGESS
DETROIT MI
48219-4804
US

V. Phone/Fax

Practice location:
  • Phone: 734-430-2402
  • Fax: 248-864-8299
Mailing address:
  • Phone: 734-430-2402
  • Fax: 248-864-8299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0900X
TaxonomyInternist Chiropractor
License Number5315023764
License Number StateMI

VIII. Authorized Official

Name: MRS. KAMITKO COLEMAN
Title or Position: OWNER
Credential:
Phone: 734-430-2402