Organization
CHANGES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LOLITA CHANDLER (GENERAL PARTNER)
(313) 368-0005
Entity
Organization
Contact information
Practice address
19940 CONANT ST, DETROIT, MI 48234-1494
(313) 368-0005
(313) 368-0771
Mailing address
19940 CONANT ST, DETROIT, MI 48234-1494
(313) 368-0005
(313) 368-0771
Taxonomy
Speciality
Code
Description
License number
State
207RA0401X
Addiction Medicine (Internal Medicine) Physician
SA0823210
MI
251B00000X
Case Management Agency
—
—
261QM2800X
Methadone Clinic
Primary
SA0823210
MI
Other
Enumeration date
07/30/2014
Last updated
07/30/2014
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