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General NPI Number Information
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NPI Number | 1770145872
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Entity Type | Organization
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Legal Business Name | EXECUTIVE CARE
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Dates
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Enumeration Date | 06/28/2019
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Last Update Date | 06/28/2019
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Provider Practice Location Address
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Address Line | 8951 RUTHERFORD ST
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City | DETROIT
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State | MI
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Zip | 48228-2131
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Country | US
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Telephone | 800-575-5290
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Fax |
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Provider Business Mailing Address
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Address Line | 8951 RUTHERFORD ST
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City | DETROIT
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State | MI
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Zip | 48228-2131
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Country | US
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Telephone | 800-575-5290
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Fax |
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Authorized Official
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Title or Position | NURSE
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Name | TISCUR GWENDOLYN TAYLOR
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Credential | LPN
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Telephone | 800-575-5270
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number |
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License Number State |
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