Healthcare Provider Details

I. General information

NPI: 1639421035
Provider Name (Legal Business Name): FAMLY MEDICAL CENTER OF MICHIGAN, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2012
Last Update Date: 10/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8765 LEWIS AVE
TEMPERANCE MI
48182-9583
US

IV. Provider business mailing address

128 S BROAD ST
ADRIAN MI
49221-2723
US

V. Phone/Fax

Practice location:
  • Phone: 734-847-3802
  • Fax: 734-850-0520
Mailing address:
  • Phone: 517-266-0651
  • Fax: 517-266-8476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateMI

VIII. Authorized Official

Name: MR. ED LARKINS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 734-850-6914