Provider Demographics
NPI:1073976239
Name:MACOMB CHILDREN'S HEALTHCARE ACCESS PROGRAM
Entity Type:Organization
Organization Name:MACOMB CHILDREN'S HEALTHCARE ACCESS PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-459-5108
Mailing Address - Street 1:11370 HUPP AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-2505
Mailing Address - Country:US
Mailing Address - Phone:586-459-5108
Mailing Address - Fax:586-459-5186
Practice Address - Street 1:11370 HUPP AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-2505
Practice Address - Country:US
Practice Address - Phone:586-459-5108
Practice Address - Fax:586-459-5186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-04
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251K00000XAgenciesPublic Health or Welfare