Healthcare Provider Details

I. General information

NPI: 1336782994
Provider Name (Legal Business Name): CORECARE MEDICAL SERVICES.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2019
Last Update Date: 01/16/2020
Certification Date: 01/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6773 STONEBRIDGE CT
WEST BLOOMFIELD MI
48322-3268
US

IV. Provider business mailing address

6773 STONEBRIDGE CT
WEST BLOOMFIELD MI
48322-3268
US

V. Phone/Fax

Practice location:
  • Phone: 313-330-1194
  • Fax: 248-855-5543
Mailing address:
  • Phone: 313-330-1194
  • Fax: 248-855-5543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: EGERTON ABULU
Title or Position: ADMINISTRATOR
Credential:
Phone: 313-330-1194