Healthcare Provider Details

I. General information

NPI: 1003613654
Provider Name (Legal Business Name): MALIK LAURY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2025
Last Update Date: 02/28/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 S. TELEGRAPH BUILDING 32 EAST
PONTIAC MI
48341
US

IV. Provider business mailing address

12808 WADE ST
DETROIT MI
48213-1867
US

V. Phone/Fax

Practice location:
  • Phone: 800-231-1127
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License Number2003096
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: