Healthcare Provider Details

I. General information

NPI: 1174906184
Provider Name (Legal Business Name): DETROIT COMMUNITY HEALTH CONNECTION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2015
Last Update Date: 07/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13901 E JEFFERSON AVE
DETROIT MI
48215-2720
US

IV. Provider business mailing address

13901 E JEFFERSON AVE
DETROIT MI
48215-2720
US

V. Phone/Fax

Practice location:
  • Phone: 313-343-2873
  • Fax: 313-822-4202
Mailing address:
  • Phone: 313-343-2873
  • Fax: 313-822-4202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

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