=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417384223
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY HEALTH AWARENESS GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2013
-----------------------------------------------------
Last Update Date | 11/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 W FORT ST
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48226-3007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-963-3434
-----------------------------------------------------
Fax | 313-963-1832
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1300 W FORT ST
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48226-3007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-963-3434
-----------------------------------------------------
Fax | 313-963-1832
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF CLINICAL SERVICES
-----------------------------------------------------
Name | MS. CHRISTINA FLUKER
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 313-963-3434
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 6801071630
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------