Basic Information
| Provider Information | |||||||||
| NPI: | 1942937149 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHN D. DINGELL VAHCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4646 JOHN R ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482011916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135761000 | ||||||||
| FaxNumber: | 3135761570 | ||||||||
| Practice Location | |||||||||
| Address1: | 4646 JOHN R ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482011916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135761000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2022 | ||||||||
| LastUpdateDate: | 08/07/2022 | ||||||||
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| AuthorizedOfficialLastName: | PETERSON | ||||||||
| AuthorizedOfficialFirstName: | ASIA | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | MENTAL HEALTH RN | ||||||||
| AuthorizedOfficialTelephone: | 3135761000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | BSN, RN | ||||||||
| NPICertificationDate: | 08/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | Y | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.