Healthcare Provider Details

I. General information

NPI: 1770418212
Provider Name (Legal Business Name): MEDIVEX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29650 TRAILWOOD DR
WARREN MI
48092-4699
US

IV. Provider business mailing address

29650 TRAILWOOD DR
WARREN MI
48092-4699
US

V. Phone/Fax

Practice location:
  • Phone: 281-216-6971
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: CHARLES HOLTON
Title or Position: SUPERVISOR
Credential:
Phone: 281-216-6971