Healthcare Provider Details

I. General information

NPI: 1518548601
Provider Name (Legal Business Name): GWENDOLYN D BUSH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2021
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23195 RIVERSIDE DR
SOUTHFIELD MI
48033-7301
US

IV. Provider business mailing address

23195 RIVERSIDE DR
SOUTHFIELD MI
48033-7301
US

V. Phone/Fax

Practice location:
  • Phone: 954-806-9411
  • Fax:
Mailing address:
  • Phone: 954-806-9411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: