Healthcare Provider Details

I. General information

NPI: 1871108217
Provider Name (Legal Business Name): ACADIAN SUPREME HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2020
Last Update Date: 09/12/2020
Certification Date: 09/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12866 FORT ST
SOUTHGATE MI
48195-1060
US

IV. Provider business mailing address

20831 RIDGEMONT RD
HARPER WOODS MI
48225-1137
US

V. Phone/Fax

Practice location:
  • Phone: 313-930-0258
  • Fax:
Mailing address:
  • Phone: 313-930-0258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: INGRID N. LEWIS
Title or Position: AUTHORIZED OFFICIAL/FNP
Credential:
Phone: 313-930-0258