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General NPI Number Information
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NPI Number | 1376210807
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Entity Type | Organization
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Legal Business Name | BOARDERS MULTISPECIALTY & PAIN CLINIC
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Dates
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Enumeration Date | 08/24/2021
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Last Update Date | 08/24/2021
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Provider Practice Location Address
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Address Line | 24423 SOUTHFIELD RD STE 120
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City | SOUTHFIELD
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State | MI
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Zip | 48075-2864
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Country | US
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Telephone | 313-510-8861
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 35
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City | SOUTHFIELD
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State | MI
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Zip | 48037-0035
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Country | US
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Telephone | 313-510-8861
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ANTHONY BANKS
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Credential |
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Telephone | 313-510-8861
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QP3300X
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Taxonomy Name | Pain Clinic/Center
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License Number |
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License Number State |
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