Healthcare Provider Details

I. General information

NPI: 1346588076
Provider Name (Legal Business Name): MR. HAROLD ALPHONSO RUDOLPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2013
Last Update Date: 01/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1852 W GRAND BLVD
DETROIT MI
48208-1006
US

IV. Provider business mailing address

1852 W GRAND BLVD
DETROIT MI
48208-1006
US

V. Phone/Fax

Practice location:
  • Phone: 313-894-8444
  • Fax: 313-894-5542
Mailing address:
  • Phone: 313-894-8444
  • Fax: 313-894-5542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number820174
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: