Healthcare Provider Details

I. General information

NPI: 1679881478
Provider Name (Legal Business Name): WAYNE COUNTY JUVENILE DETENTION FACILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2010
Last Update Date: 09/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1326 SAINT ANTOINE ST
DETROIT MI
48226-2301
US

IV. Provider business mailing address

1326 SAINT ANTOINE ST
DETROIT MI
48226-2301
US

V. Phone/Fax

Practice location:
  • Phone: 313-967-2050
  • Fax: 313-967-6552
Mailing address:
  • Phone: 313-967-2050
  • Fax: 313-967-6552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License NumberCE820201498
License Number StateMI

VIII. Authorized Official

Name: MR. TADARIAL STURDIVANT
Title or Position: DIRECTOR
Credential:
Phone: 313-833-7125