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General NPI Number Information
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NPI Number | 1205339306
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Entity Type | Organization
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Legal Business Name | CONANT FAMILY CARE PLLC
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Dates
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Enumeration Date | 03/14/2018
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Last Update Date | 05/01/2018
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Provider Practice Location Address
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Address Line | 3611 CARPENTER ST STE 5
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City | DETROIT
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State | MI
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Zip | 48212-2784
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Country | US
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Telephone | 917-588-1632
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Fax |
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Provider Business Mailing Address
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Address Line | 3611 CARPENTER ST STE 5
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City | DETROIT
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State | MI
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Zip | 48212-2784
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MASUDA POLI
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Credential |
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Telephone | 917-588-1632
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 4301073086
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License Number State | MI
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