Healthcare Provider Details

I. General information

NPI: 1992511166
Provider Name (Legal Business Name): DWAYNE SCOTT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2024
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 E GRAND BLVD APT 208
DETROIT MI
48207-3777
US

IV. Provider business mailing address

27378 PARKVIEW BLVD APT 4314
WARREN MI
48092-3501
US

V. Phone/Fax

Practice location:
  • Phone: 586-339-2178
  • Fax:
Mailing address:
  • Phone: 586-339-2178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: