MEDICARE: CROWN PROCEDURE CENTER LLC

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	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1114429891
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROWN PROCEDURE CENTER LLC

Provider Business Mailing Address
First Line	:	28373 DEQUINDRE RD STE B
Second Line	:
City	:	MADISON HEIGHTS
State	:	MI
Zip	:	48071-3003
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	28373 DEQUINDRE RD STE B
Second Line	:
City	:	MADISON HEIGHTS
State	:	MI
Zip	:	48071-3003
Country	:	US
Telephone Number	:	248-843-4553
Fax Number	:

Authorized Official
Title or Position	:	MEMEBER
Name	:	MUNA AFAN
Credential	:
Telephone Number	:	248-843-4553

Provider Enumeration Date	:	03/08/2018
Last Update Date	:	03/08/2018

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