Healthcare Provider Details

I. General information

NPI: 1942618228
Provider Name (Legal Business Name): CHANGES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2014
Last Update Date: 07/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19940 CONANT ST
DETROIT MI
48234-1494
US

IV. Provider business mailing address

19940 CONANT ST
DETROIT MI
48234-1494
US

V. Phone/Fax

Practice location:
  • Phone: 313-368-0005
  • Fax: 313-368-0771
Mailing address:
  • Phone: 313-368-0005
  • Fax: 313-368-0771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License NumberSA0823210
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License NumberSA0823210
License Number StateMI

VIII. Authorized Official

Name: LOLITA CHANDLER
Title or Position: GENERAL PARTNER
Credential:
Phone: 313-368-0005