Healthcare Provider Details

I. General information

NPI: 1609400522
Provider Name (Legal Business Name): VICKIE GAINES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/29/2020
Last Update Date: 07/21/2022
Certification Date: 02/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28096 PALOMINO DR
WARREN MI
48093-4232
US

IV. Provider business mailing address

28096 PALOMINO DR
WARREN MI
48093-4232
US

V. Phone/Fax

Practice location:
  • Phone: 313-288-0003
  • Fax:
Mailing address:
  • Phone: 313-288-0003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: