MEDICARE: MACK ADVANCED 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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1134075880
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MACK ADVANCED CENTER, LLC

Provider Business Mailing Address
First Line	:	7612 GRATIOT AVE STE 2
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48213-2822
Country	:	US
Telephone Number	:	313-548-3787
Fax Number	:

Provider Business Practice Location Address
First Line	:	7612 GRATIOT AVE STE 2
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48213-2822
Country	:	US
Telephone Number	:	313-548-3787
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	LAKEISHA WILLIAMS
Credential	:
Telephone Number	:	313-548-3787

Provider Enumeration Date	:	03/05/2026
Last Update Date	:	03/05/2026

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Directions to “MACK ADVANCED CENTER, LLC ” Practice Location

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