Healthcare Provider Details

I. General information

NPI: 1134075880
Provider Name (Legal Business Name): MACK ADVANCED CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7612 GRATIOT AVE STE 2
DETROIT MI
48213-2822
US

IV. Provider business mailing address

2751 E JEFFERSON AVE STE 400
DETROIT MI
48207-4105
US

V. Phone/Fax

Practice location:
  • Phone: 313-548-3787
  • Fax:
Mailing address:
  • Phone: 313-444-1242
  • Fax: 313-279-7126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LAKEISHA WILLIAMS
Title or Position: OFFICE MANAGER
Credential:
Phone: 313-548-3787