Healthcare Provider Details

I. General information

NPI: 1073976239
Provider Name (Legal Business Name): MACOMB CHILDREN'S HEALTHCARE ACCESS PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 04/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11370 HUPP AVE
WARREN MI
48089-2505
US

IV. Provider business mailing address

11370 HUPP AVE
WARREN MI
48089-2505
US

V. Phone/Fax

Practice location:
  • Phone: 586-459-5108
  • Fax: 586-459-5186
Mailing address:
  • Phone: 586-459-5108
  • Fax: 586-459-5186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. MONICA WOODSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 586-459-5108