Healthcare Provider Details

I. General information

NPI: 1306990767
Provider Name (Legal Business Name): KEVIN J DAMICO CNMT & AART(N)
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

983 WING ST
PLYMOUTH MI
48170-1725
US

IV. Provider business mailing address

983 WING ST
PLYMOUTH MI
48170-1725
US

V. Phone/Fax

Practice location:
  • Phone: 734-414-7056
  • Fax: 734-414-9925
Mailing address:
  • Phone: 734-414-7056
  • Fax: 734-414-9925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471N0900X
TaxonomyNuclear Medicine Technology Radiologic Technologist
License Number007988 & 193875
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: