Healthcare Provider Details

I. General information

NPI: 1265647200
Provider Name (Legal Business Name): MICHELE JOANN ROACH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

18311 CEDAR ISLAND BLVD
BROWNSTOWN MI
48174-9585
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-1231
  • Fax:
Mailing address:
  • Phone: 313-995-0551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number3701-0106-0953-552
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: