Healthcare Provider Details

I. General information

NPI: 1104074582
Provider Name (Legal Business Name): FRIENDLY NEIGHBORHOOD MEDICAL CLINIC II
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2008
Last Update Date: 10/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18606 FENKELL ST
DETROIT MI
48223-2315
US

IV. Provider business mailing address

18606 FENKELL ST
DETROIT MI
48223-2315
US

V. Phone/Fax

Practice location:
  • Phone: 313-273-2000
  • Fax: 313-273-2020
Mailing address:
  • Phone: 313-273-2000
  • Fax: 313-273-2020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. NANCY ROCHELLE WILLIAMS
Title or Position: OWNER/CEO
Credential:
Phone: 313-273-2000