Healthcare Provider Details

I. General information

NPI: 1134745995
Provider Name (Legal Business Name): JUANITA CHARLESTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2020
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15941 FAIRFIELD ST
DETROIT MI
48238-4123
US

IV. Provider business mailing address

15941 FAIRFIELD ST
DETROIT MI
48238-4123
US

V. Phone/Fax

Practice location:
  • Phone: 313-855-6035
  • Fax: 313-345-4592
Mailing address:
  • Phone: 313-345-4310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: