Healthcare Provider Details

I. General information

NPI: 1891468807
Provider Name (Legal Business Name): CHARLES CHISOM OBI RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2021
Last Update Date: 07/26/2021
Certification Date: 07/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CAMPBELL ST
RIVER ROUGE MI
48218-1011
US

IV. Provider business mailing address

300 CAMPBELL ST
RIVER ROUGE MI
48218-1011
US

V. Phone/Fax

Practice location:
  • Phone: 313-744-2001
  • Fax:
Mailing address:
  • Phone: 313-744-2001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: