| NPI | 1669552931 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | SANDRA J JACKSON Executive Director 313-561-3360 |
| Organization Subpart ? | No |
| Primary Taxonomy | 302F00000X Exclusive Provider Organization |
| Additional Taxonomies | 302F00000X Exclusive Provider Organization (Licence: MI AS20014119) |
| 302F00000X Exclusive Provider Organization | |
| Enumeration Date | 2006-10-17 |
| Last Update Date | 2020-08-22 |