Healthcare Provider Details

I. General information

NPI: 1124933163
Provider Name (Legal Business Name): PINKNIFICENT PROSTHETIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2026
Last Update Date: 08/15/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15811 KENTFIELD ST
DETROIT MI
48223-1246
US

IV. Provider business mailing address

15811 KENTFIELD ST
DETROIT MI
48223-1246
US

V. Phone/Fax

Practice location:
  • Phone: 313-268-0859
  • Fax:
Mailing address:
  • Phone: 313-400-3039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name: MRS. TIFFANY EASLEY
Title or Position: OWNER
Credential: CRANIAL PROSTHESIS
Phone: 313-268-0859