Healthcare Provider Details

I. General information

NPI: 1053542498
Provider Name (Legal Business Name): NORTHEAST GUIDANCE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2009
Last Update Date: 08/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20303 KELLY RD
DETROIT MI
48225-1206
US

IV. Provider business mailing address

20303 KELLY RD
DETROIT MI
48225-1206
US

V. Phone/Fax

Practice location:
  • Phone: 313-245-7000
  • Fax: 313-245-7009
Mailing address:
  • Phone: 313-245-7000
  • Fax: 313-245-7009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number StateMI

VIII. Authorized Official

Name: MR. ADAM WEINGARDEN
Title or Position: HOSPITAL LIAISON
Credential:
Phone: 313-550-9167