Healthcare Provider Details

I. General information

NPI: 1225669112
Provider Name (Legal Business Name): JEVRON MANASAN MACALINO JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2020
Last Update Date: 11/27/2023
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12250 E 12 MILE RD
WARREN MI
48093-3516
US

IV. Provider business mailing address

12250 E 12 MILE RD
WARREN MI
48093-3516
US

V. Phone/Fax

Practice location:
  • Phone: 586-571-1019
  • Fax: 586-751-3785
Mailing address:
  • Phone: 586-571-1019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number5201010453
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: