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General NPI Number Information
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NPI Number | 1679775308
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Entity Type | Organization
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Legal Business Name | CHOCTAW MANAGEMENT SERVICES ENTERPRISE
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Dates
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Enumeration Date | 06/04/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1172 KIRTS BLVD U.S. MEPS
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City | TROY
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State | MI
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Zip | 48084-4846
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Country | US
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Telephone | 248-244-9131
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Fax |
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Provider Business Mailing Address
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Address Line | 2773 MAYFAIR DR
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City | TROY
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State | MI
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Zip | 48084-2601
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Country | US
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Telephone | 248-649-1042
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Fax |
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Authorized Official
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Title or Position | PROGRAM COORDINATOR
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Name | MS. AMY HUMPHREY
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Credential |
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Telephone | 877-267-3728
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171000000X
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Taxonomy Name | Military Health Care Provider
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License Number | 4301037778
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License Number State | MI
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