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NPI Code Detail

MEDICARE: STACEY JUNIOR

MEDICARE: STACEY JUNIOR
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
1372500000XChore ProviderMI

General Provider Information

NPI Number : 1962874156
Entity Type Code : Individual
Provider Name (Legal Business Name) : STACEY JUNIOR
Provider Business Mailing Address
First Line : 94 E HENRY ST
Second Line :
City : RIVER ROUGE
State : MI
Zip : 48218-1640
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 94 E HENRY ST
Second Line :
City : RIVER ROUGE
State : MI
Zip : 48218-1640
Country : US
Telephone Number : 313-300-9711
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/27/2015
Last Update Date : 10/27/2015

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Directions to “ STACEY JUNIOR ” Practice Location

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