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General NPI Number Information
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NPI Number | 1093904500
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Entity Type | Organization
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Legal Business Name | SENTINEL WOUND CARE ASSOCIATES PC
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Dates
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Enumeration Date | 10/21/2007
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Last Update Date | 10/21/2007
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Provider Practice Location Address
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Address Line | 19697 DRIFTWOOD DR
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City | CLINTON TOWNSHIP
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State | MI
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Zip | 48038-6906
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Country | US
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Telephone | 586-286-6389
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Fax | 586-226-0403
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Provider Business Mailing Address
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Address Line | 19697 DRIFTWOOD DR
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City | CLINTON TOWNSHIP
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State | MI
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Zip | 48038-6906
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Country | US
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Telephone | 586-286-6389
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Fax | 586-226-0403
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Authorized Official
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Title or Position | PRESIDENT
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Name | LOIS MICHELLE BUTLER-JACKSON
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Credential | M.D.
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Telephone | 586-286-6389
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 4301051182
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License Number State | MI
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