Healthcare Provider Details

I. General information

NPI: 1679775308
Provider Name (Legal Business Name): CHOCTAW MANAGEMENT SERVICES ENTERPRISE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1172 KIRTS BLVD U.S. MEPS
TROY MI
48084-4846
US

IV. Provider business mailing address

2773 MAYFAIR DR
TROY MI
48084-2601
US

V. Phone/Fax

Practice location:
  • Phone: 248-244-9131
  • Fax:
Mailing address:
  • Phone: 248-649-1042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number4301037778
License Number StateMI

VIII. Authorized Official

Name: MS. AMY HUMPHREY
Title or Position: PROGRAM COORDINATOR
Credential:
Phone: 877-267-3728