Healthcare Provider Details

I. General information

NPI: 1992183388
Provider Name (Legal Business Name): MRS. SOPHIA LORRAINE ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2015
Last Update Date: 05/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22828 GAUKLER ST 22828 GAUKLER STREET
SAINT CLAIR SHORES MI
48080-2543
US

IV. Provider business mailing address

22828 GAUKLER ST
SAINT CLAIR SHORES MI
48080-2543
US

V. Phone/Fax

Practice location:
  • Phone: 586-944-0020
  • Fax:
Mailing address:
  • Phone: 586-944-0020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License NumberA536772546878
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: