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General NPI Number Information
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NPI Number | 1891405031
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Entity Type | Organization
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Legal Business Name | PURE HEALTH OF MICHIGAN
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Dates
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Enumeration Date | 11/29/2022
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Last Update Date | 12/26/2022
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Provider Practice Location Address
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Address Line | 17800 NORTHLAND PARK CT
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City | SOUTHFIELD
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State | MI
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Zip | 48075-4304
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Country | US
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Telephone | 248-233-4076
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Fax | 248-233-4079
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Provider Business Mailing Address
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Address Line | 17800 NORTHLAND PARK CT
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City | SOUTHFIELD
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State | MI
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Zip | 48075-4304
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Country | US
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Telephone | 248-233-4076
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Fax | 248-233-4079
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Authorized Official
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Title or Position | OFFICE DIRECTOR
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Name | ANTOINE TUCKER
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Credential |
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Telephone | 248-233-4076
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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