Healthcare Provider Details

I. General information

NPI: 1316315575
Provider Name (Legal Business Name): ST CLAIR ADULT CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2015
Last Update Date: 09/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25932 DEQUINDRE RD STE. C
WARREN MI
48091-1071
US

IV. Provider business mailing address

25932 DEQUINDRE RD STE. C
WARREN MI
48091-1071
US

V. Phone/Fax

Practice location:
  • Phone: 248-859-6369
  • Fax: 586-486-5552
Mailing address:
  • Phone: 248-859-6369
  • Fax: 586-486-5552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301039079
License Number StateMI

VIII. Authorized Official

Name: DR. THEODORE DENSLEY
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 248-859-6369