Individual
JUANITA CHARLESTON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
15941 FAIRFIELD ST, DETROIT, MI 48238-4123
(313) 855-6035
(313) 345-4592
Mailing address
15941 FAIRFIELD ST, DETROIT, MI 48238-4123
(313) 345-4310
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
363849916
—
MI
Enumeration date
06/17/2020
Last updated
06/17/2020
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