Healthcare Provider Details

I. General information

NPI: 1750104071
Provider Name (Legal Business Name): DETROIT COMMUNITY CARE NETWORK L3C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2024
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12850 PLYMOUTH RD
DETROIT MI
48227-3725
US

IV. Provider business mailing address

21549 VIRGINIA ST
SOUTHFIELD MI
48076-2364
US

V. Phone/Fax

Practice location:
  • Phone: 313-636-1801
  • Fax:
Mailing address:
  • Phone: 313-636-1801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name: DAVID UNDERWOOD
Title or Position: MANAGING DIRECTOR
Credential:
Phone: 313-636-1801