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General NPI Number Information
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NPI Number | 1427266113
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Entity Type | Organization
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Legal Business Name | GODDARD CLINIC PC
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Dates
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Enumeration Date | 05/18/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 17234 GODDARD RD
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City | ALLEN PARK
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State | MI
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Zip | 48101-4100
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Country | US
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Telephone | 313-386-3960
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Fax | 313-386-0145
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Provider Business Mailing Address
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Address Line | 17234 GODDARD RD
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City | ALLEN PARK
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State | MI
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Zip | 48101-4100
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Country | US
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Telephone | 313-386-3960
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Fax | 313-386-0145
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KENNETH WILLIAM DEBYLE
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Credential | D.O.
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Telephone | 313-386-3960
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 5101005616
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License Number State | MI
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