Healthcare Provider Details

I. General information

NPI: 1780284810
Provider Name (Legal Business Name): KEVIN L WARREN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2020
Last Update Date: 10/28/2020
Certification Date: 10/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6032 CHAMBERLAIN ST
ROMULUS MI
48174-1810
US

IV. Provider business mailing address

6032 CHAMBERLAIN ST
ROMULUS MI
48174-1810
US

V. Phone/Fax

Practice location:
  • Phone: 734-833-4724
  • Fax:
Mailing address:
  • Phone: 734-833-4724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: