Basic Information
| Provider Information | |||||||||
| NPI: | 1942507520 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ARAB AMERICAN CHALDEAN COUNCIL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 62 W 7 MILE RD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482031967 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 62 W 7 MILE RD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482031967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138936172 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2011 | ||||||||
| LastUpdateDate: | 02/17/2011 | ||||||||
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| AuthorizedOfficialLastName: | SARAFA | ||||||||
| AuthorizedOfficialFirstName: | CARMEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 3138936172 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 6401012155 | MI | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 3434247 | 05 | MI | MEDICAID |