Healthcare Provider Details

I. General information

NPI: 1356689764
Provider Name (Legal Business Name): MARJORIE CAROL AL-KHATIB MEDICAL ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2013
Last Update Date: 01/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13101 ALLEN RD
SOUTHGATE MI
48195-2216
US

IV. Provider business mailing address

5714 W HICKORY HOLLOW ST
WAYNE MI
48184-2651
US

V. Phone/Fax

Practice location:
  • Phone: 734-785-7701
  • Fax:
Mailing address:
  • Phone: 313-828-7624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: