Healthcare Provider Details

I. General information

NPI: 1003485830
Provider Name (Legal Business Name): PACE SOUTHEAST MICHIGAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17401 E 10 MILE RD
EASTPOINTE MI
48021-1256
US

IV. Provider business mailing address

21700 NORTHWESTERN HWY
SOUTHFIELD MI
48075-4906
US

V. Phone/Fax

Practice location:
  • Phone: 855-445-4554
  • Fax:
Mailing address:
  • Phone: 855-445-4554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: BRYAN DOVICHI
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 313-269-7744