Healthcare Provider Details

I. General information

NPI: 1376280131
Provider Name (Legal Business Name): JOHN DOUGLASS ORR JR. RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2022
Last Update Date: 05/13/2022
Certification Date: 05/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6309 MACK AVE
DETROIT MI
48207-2302
US

IV. Provider business mailing address

41021 OLD MICHIGAN AVE TRLR 185
CANTON MI
48188-2726
US

V. Phone/Fax

Practice location:
  • Phone: 313-331-3435
  • Fax:
Mailing address:
  • Phone: 313-773-6098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704301657
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: