Healthcare Provider Details

I. General information

NPI: 1417384223
Provider Name (Legal Business Name): COMMUNITY HEALTH AWARENESS GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2013
Last Update Date: 11/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 W FORT ST
DETROIT MI
48226-3007
US

IV. Provider business mailing address

1300 W FORT ST
DETROIT MI
48226-3007
US

V. Phone/Fax

Practice location:
  • Phone: 313-963-3434
  • Fax: 313-963-1832
Mailing address:
  • Phone: 313-963-3434
  • Fax: 313-963-1832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number6801071630
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: MS. CHRISTINA FLUKER
Title or Position: DIRECTOR OF CLINICAL SERVICES
Credential: LMSW
Phone: 313-963-3434