Healthcare Provider Details

I. General information

NPI: 1588137376
Provider Name (Legal Business Name): DETROIT COMMUNITY HEALTH CONNECTION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2019
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20303 KELLY RD
DETROIT MI
48225-1206
US

IV. Provider business mailing address

13901 E JEFFERSON AVE
DETROIT MI
48215-2720
US

V. Phone/Fax

Practice location:
  • Phone: 313-347-2116
  • Fax: 313-245-7009
Mailing address:
  • Phone: 313-821-2591
  • Fax: 313-822-4202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MAHIPAL RAO KAKARALA
Title or Position: SR VP & CFO
Credential:
Phone: 313-821-2591