Healthcare Provider Details

I. General information

NPI: 1417292970
Provider Name (Legal Business Name): DALLAS FULLMER CCP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2012
Last Update Date: 12/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31330 SCHOOLCRAFT RD STE 200
LIVONIA MI
48150-2041
US

IV. Provider business mailing address

31330 SCHOOLCRAFT RD STE 200
LIVONIA MI
48150-2041
US

V. Phone/Fax

Practice location:
  • Phone: 734-525-9712
  • Fax:
Mailing address:
  • Phone: 734-525-9712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code242T00000X
TaxonomyPerfusionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: