Provider Demographics
NPI:1063036739
Name:CHILDERS, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:CHILDERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8390 ISLANDVIEW CT
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-8789
Mailing Address - Country:US
Mailing Address - Phone:810-908-8757
Mailing Address - Fax:
Practice Address - Street 1:11885 E 12 MILE RD STE 300A
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3467
Practice Address - Country:US
Practice Address - Phone:586-582-6630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-29
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program