Healthcare Provider Details

I. General information

NPI: 1881908283
Provider Name (Legal Business Name): ABYSSININ LOVEKNOT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2010
Last Update Date: 07/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21700 GREENFIELD RD 215B
OAK PARK MI
48237-2581
US

IV. Provider business mailing address

21700 GREENFIELD RD 215B
OAK PARK MI
48237-2581
US

V. Phone/Fax

Practice location:
  • Phone: 248-968-6899
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MALIK FUQUA
Title or Position: OWNER
Credential:
Phone: 248-968-6899