Healthcare Provider Details

I. General information

NPI: 1770752495
Provider Name (Legal Business Name): ALPHA AND OMEGA PRIMARY HEALTH CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2008
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15865 WYOMING ST
DETROIT MI
48238-1136
US

IV. Provider business mailing address

15865 WYOMING ST
DETROIT MI
48238-1136
US

V. Phone/Fax

Practice location:
  • Phone: 313-342-2576
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301061729
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301061729
License Number StateMI

VIII. Authorized Official

Name: DR. RICKIE HARDAWAY
Title or Position: OWNER
Credential: M.D.
Phone: 313-342-2576