Provider Demographics
NPI:1013558386
Name:INTEGRATED CARE CLINICIANS, LLC
Entity Type:Organization
Organization Name:INTEGRATED CARE CLINICIANS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BARBRENE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHLULI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-673-8636
Mailing Address - Street 1:989 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-1885
Mailing Address - Country:US
Mailing Address - Phone:248-818-1249
Mailing Address - Fax:
Practice Address - Street 1:989 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342-1885
Practice Address - Country:US
Practice Address - Phone:248-818-1249
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone