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General NPI Number Information
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NPI Number | 1760979959
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Entity Type | Organization
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Legal Business Name | MY PLACE AFC
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Dates
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Enumeration Date | 04/13/2018
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Last Update Date | 04/13/2018
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Provider Practice Location Address
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Address Line | 21415 SHERMAN AVE
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City | SOUTHFIELD
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State | MI
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Zip | 48033-4388
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Country | US
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Telephone | 313-510-2879
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Fax | 248-559-5692
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Provider Business Mailing Address
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Address Line | 15565 NORTHLAND DR E STE 901
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City | SOUTHFIELD
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State | MI
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Zip | 48075-5331
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Country | US
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Telephone | 248-559-5683
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MRS. SAMANTHA M EVANS
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Credential |
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Telephone | 313-510-2879
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 172V00000X
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Taxonomy Name | Community Health Worker
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License Number |
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License Number State |
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