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NPI Code Detail

MEDICARE: NORTHWEST INDUSTRIAL DRUG REHABILITATION CLINIC

MEDICARE: NORTHWEST INDUSTRIAL DRUG REHABILITATION CLINIC
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
1261QM2800XMethadone Clinic

General Provider Information

NPI Number : 1821112103
Entity Type Code : Organization
Provider Name (Legal Business Name) : NORTHWEST INDUSTRIAL DRUG REHABILITATION CLINIC
Provider Business Mailing Address
First Line : 9600 DEXTER AVE
Second Line :
City : DETROIT
State : MI
Zip : 48206-1816
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 9600 DEXTER AVE
Second Line :
City : DETROIT
State : MI
Zip : 48206-1816
Country : US
Telephone Number : 313-894-6379
Fax Number :
Authorized Official
Title or Position : OWNER PRESIDENT
Name : CARL DENNIS FOWLER
Credential : M.D.
Telephone Number : 313-894-4879
Provider Enumeration Date : 03/19/2007
Last Update Date : 08/22/2020

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Directions to “NORTHWEST INDUSTRIAL DRUG REHABILITATION CLINIC ” Practice Location

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