Provider Demographics
NPI:1134634322
Name:DYNASTY NETWORK
Entity Type:Organization
Organization Name:DYNASTY NETWORK
Other - Org Name:DYNASTY FAMILY HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CLARA
Authorized Official - Middle Name:
Authorized Official - Last Name:THROCKMORTON
Authorized Official - Suffix:
Authorized Official - Credentials:LAMS
Authorized Official - Phone:734-678-1363
Mailing Address - Street 1:40560 DOUGLAS DR APT 204
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-1357
Mailing Address - Country:US
Mailing Address - Phone:734-678-1363
Mailing Address - Fax:
Practice Address - Street 1:40560 DOUGLAS DR APT 204
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-1357
Practice Address - Country:US
Practice Address - Phone:734-678-1363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-09
Last Update Date:2017-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management