Healthcare Provider Details

I. General information

NPI: 1710460779
Provider Name (Legal Business Name): JOSEPH ROBERT GENDRON RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 09/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14799 DIX TOLEDO RD
SOUTHGATE MI
48195-2507
US

IV. Provider business mailing address

14799 DIX TOLEDO RD
SOUTHGATE MI
48195-2507
US

V. Phone/Fax

Practice location:
  • Phone: 734-324-8326
  • Fax: 734-324-8327
Mailing address:
  • Phone: 734-324-8326
  • Fax: 734-324-8327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number4704343929
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: