Healthcare Provider Details

I. General information

NPI: 1477857365
Provider Name (Legal Business Name): DETROIT INSTITUTE FOR CHILDREN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2011
Last Update Date: 04/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19505 E 8 MILE RD
SAINT CLAIR SHORES MI
48080-1643
US

IV. Provider business mailing address

19505 E 8 MILE RD
SAINT CLAIR SHORES MI
48080-1643
US

V. Phone/Fax

Practice location:
  • Phone: 586-445-8200
  • Fax: 586-445-8201
Mailing address:
  • Phone: 586-445-8200
  • Fax: 586-445-8201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MR. MARK CLEARY
Title or Position: PRESIDENT/CEO
Credential:
Phone: 313-832-1100