Healthcare Provider Details

I. General information

NPI: 1306395546
Provider Name (Legal Business Name): DEFPOTEC CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2016
Last Update Date: 10/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17260 W 10 MILE RD
SOUTHFIELD MI
48075-2949
US

IV. Provider business mailing address

14200 W 8 MILE RD 37047
OAK PARK MI
48237-7700
US

V. Phone/Fax

Practice location:
  • Phone: 248-809-4633
  • Fax:
Mailing address:
  • Phone: 313-455-4146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code132700000X
TaxonomyDietary Manager
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code163WP0000X
TaxonomyPain Management Registered Nurse
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State

VIII. Authorized Official

Name: MS. KRISTIE VOLAURA LEE
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 248-595-8271