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General NPI Number Information
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NPI Number | 1245771294
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Entity Type | Organization
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Legal Business Name | MISSIONARY SERVANTS OF DIVINE PROVIDENCE
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Dates
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Enumeration Date | 03/10/2017
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Last Update Date | 03/10/2017
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Provider Practice Location Address
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Address Line | 26629 HOPKINS ST
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City | INKSTER
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State | MI
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Zip | 48141-3111
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Country | US
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Telephone | 734-560-5014
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Fax |
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Provider Business Mailing Address
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Address Line | 26629 HOPKINS ST
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City | INKSTER
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State | MI
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Zip | 48141-3111
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Country | US
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Telephone | 734-560-5014
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/ADMINISTRATOR
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Name | JUSTINA UDEAGHA
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Credential |
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Telephone | 734-560-5014
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 4704294907
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License Number State | MI
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