Basic Information
| Provider Information | |||||||||
| NPI: | 1124393160 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DETROIT COMMUNITY HEALTH CONNECTION, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DAAA/DETROIT COMMUNITY HEALTH CONNECTION, INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13901 E JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482152720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138212591 | ||||||||
| FaxNumber: | 3138224202 | ||||||||
| Practice Location | |||||||||
| Address1: | 12800 E WARREN AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482152061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138212591 | ||||||||
| FaxNumber: | 3138224202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2012 | ||||||||
| LastUpdateDate: | 03/08/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KAKARALA | ||||||||
| AuthorizedOfficialFirstName: | MAHIPAL | ||||||||
| AuthorizedOfficialMiddleName: | RAO | ||||||||
| AuthorizedOfficialTitleorPosition: | SRVP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 3138212591 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DETROIT COMMUNITY HEALTH CONNECTION, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.