=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679737480
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DETROIT COMMUNITY HEALTH CONNECTION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2008
-----------------------------------------------------
Last Update Date | 03/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7900 KERCHEVAL ST
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48214-2439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-924-9798
-----------------------------------------------------
Fax | 313-924-6244
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7900 KERCHEVAL STREET
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-924-9798
-----------------------------------------------------
Fax | 313-924-6244
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT & CEO
-----------------------------------------------------
Name | WAYNE W BRADLEY SR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-343-2891
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0002X
-----------------------------------------------------
Taxonomy Name | Clinic Pharmacy
-----------------------------------------------------
License Number | 5301008896
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------