Healthcare Provider Details

I. General information

NPI: 1710802053
Provider Name (Legal Business Name): STAN WILLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

29238 CAMBRIDGE ST
FLAT ROCK MI
48134-1404
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-5365
  • Fax:
Mailing address:
  • Phone: 313-587-7320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: