MEDICARE: ANTONIO CLINTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1093525024
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTONIO CLINTON

Provider Business Mailing Address
First Line	:	7111 W OUTER DR
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48235-3168
Country	:	US
Telephone Number	:	313-808-5673
Fax Number	:

Provider Business Practice Location Address
First Line	:	7111 W OUTER DR
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48235-3168
Country	:	US
Telephone Number	:	313-808-5673
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2025
Last Update Date	:	01/11/2025

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Directions to “ ANTONIO CLINTON ” Practice Location

Language	Start Address	Practice Location

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