Healthcare Provider Details

I. General information

NPI: 1659899623
Provider Name (Legal Business Name): MARTIN UNACHUKWU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2017
Last Update Date: 08/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 FARNUM ST.
INKSTER MI
48141
US

IV. Provider business mailing address

3650 FARNUM ST
INKSTER MI
48141-2021
US

V. Phone/Fax

Practice location:
  • Phone: 734-844-6533
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703118002
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: