Basic Information
| Provider Information | |||||||||
| NPI: | 1831709641 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | URBAN MINORITY ALCOHOLISM AND DRUG ABUSE OUTREACH PROGRAM OF LUCAS CTY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 33872 YORKRIDGE ST | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483311550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192972553 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2447 NEBRASKA AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436073531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192554444 | ||||||||
| FaxNumber: | 4195311596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2020 | ||||||||
| LastUpdateDate: | 08/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | SCOTT | ||||||||
| AuthorizedOfficialFirstName: | TERRELL | ||||||||
| AuthorizedOfficialMiddleName: | RHAJON | ||||||||
| AuthorizedOfficialTitleorPosition: | CORPORATE COMPLIANCE | ||||||||
| AuthorizedOfficialTelephone: | 4192972553 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 01-7673 | 05 | OH | MEDICAID |