Healthcare Provider Details

I. General information

NPI: 1033914643
Provider Name (Legal Business Name): MR. PERRON DAQUINTA HURSTON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2025
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9130 MENDOTA ST
DETROIT MI
48204-2649
US

IV. Provider business mailing address

9130 MENDOTA ST
DETROIT MI
48204-2649
US

V. Phone/Fax

Practice location:
  • Phone: 313-938-5238
  • Fax:
Mailing address:
  • Phone: 313-938-5238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number133527334
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: