Healthcare Provider Details

I. General information

NPI: 1164044624
Provider Name (Legal Business Name): VERNOR M
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2020
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7649 W VERNOR HWY
DETROIT MI
48209-1513
US

IV. Provider business mailing address

7649 W VERNOR HWY
DETROIT MI
48209-1513
US

V. Phone/Fax

Practice location:
  • Phone: 313-841-0395
  • Fax:
Mailing address:
  • Phone: 313-841-0395
  • Fax:

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 Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. BRENDA ALLENDE
Title or Position: MANAGER
Credential:
Phone: 313-841-0395