=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790259307
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FUTURE DIAGNOSTIC CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2019
-----------------------------------------------------
Last Update Date | 05/07/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4619 ALLEN RD
-----------------------------------------------------
City | ALLEN PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48101-2765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-656-1199
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4619 ALLEN RD
-----------------------------------------------------
City | ALLEN PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48101-2765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANWAR BAKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-505-4890
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------