=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386122059
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CANCER HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2018
-----------------------------------------------------
Last Update Date | 08/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18600 W 10 MILE RD STE 111
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48075-2645
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-736-3340
-----------------------------------------------------
Fax | 313-736-3340
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18600 W 10 MILE RD STE 111
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48075-2645
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-632-0003
-----------------------------------------------------
Fax | 313-736-3340
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | MS. VALERIE R. WILLIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-632-0003
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------