Healthcare Provider Details

I. General information

NPI: 1821112103
Provider Name (Legal Business Name): NORTHWEST INDUSTRIAL DRUG REHABILITATION CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9600 DEXTER AVE
DETROIT MI
48206-1816
US

IV. Provider business mailing address

9600 DEXTER AVE
DETROIT MI
48206-1816
US

V. Phone/Fax

Practice location:
  • Phone: 313-894-6379
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State

VIII. Authorized Official

Name: CARL DENNIS FOWLER
Title or Position: OWNER PRESIDENT
Credential: M.D.
Phone: 313-894-4879