Organization
WOODWARD BOULEVARD MEDICAL BUILDING
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LATONYA WALLACE-HARDIMAN BA, MSA (OWNER)
(313) 715-7170
Entity
Organization
Contact information
Practice address
5830 CONNER ST, DETROIT, MI 48213-3458
(313) 924-1456
(313) 636-2290
Mailing address
5830 CONNER ST, DETROIT, MI 48213-3458
(313) 458-8804
(313) 636-2290
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1053818039
N/A
MI
Enumeration date
07/19/2018
Last updated
11/13/2020
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