Healthcare Provider Details

I. General information

NPI: 1629328380
Provider Name (Legal Business Name): DEWBERRY MEDICAL CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2012
Last Update Date: 05/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25525 ELBA
REDFORD MI
48239-3205
US

IV. Provider business mailing address

25525 ELBA
REDFORD MI
48239-3205
US

V. Phone/Fax

Practice location:
  • Phone: 734-644-1804
  • Fax: 734-661-6339
Mailing address:
  • Phone: 734-644-1804
  • Fax: 734-661-6339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. TORIANO ARMAND DEWBERRY
Title or Position: OWNER
Credential:
Phone: 734-644-1804