=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750056099
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICAL CARE COORDINATORS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2021
-----------------------------------------------------
Last Update Date | 08/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14323 E 11 MILE RD
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48088-4839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-294-0770
-----------------------------------------------------
Fax | 586-294-7880
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14323 E 11 MILE RD
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48088-4839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-294-0770
-----------------------------------------------------
Fax | 586-294-7880
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. SUE ELLEN JURCAK
-----------------------------------------------------
Credential | MA, LPC, CDMS, CCM
-----------------------------------------------------
Telephone | 586-294-0770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------