=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831996115
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED CARE CENTER PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2025
-----------------------------------------------------
Last Update Date | 09/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1340 S COMMERCE RD
-----------------------------------------------------
City | WALLED LAKE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48390-3010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-438-6600
-----------------------------------------------------
Fax | 248-313-9210
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1340 S COMMERCE RD
-----------------------------------------------------
City | WALLED LAKE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48390-3010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-438-6600
-----------------------------------------------------
Fax | 248-313-9210
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MGR
-----------------------------------------------------
Name | MR. MOE WILCOX
-----------------------------------------------------
Credential | MGR
-----------------------------------------------------
Telephone | 419-376-5856
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------