Healthcare Provider Details

I. General information

NPI: 1679047427
Provider Name (Legal Business Name): CANDICE TAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2019
Last Update Date: 01/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 WATERMAN ST
DETROIT MI
48209-2022
US

IV. Provider business mailing address

1720 BAGLEY ST
DETROIT MI
48216-1911
US

V. Phone/Fax

Practice location:
  • Phone: 313-841-8900
  • Fax: 313-849-2702
Mailing address:
  • Phone: 313-550-0715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: