Provider Demographics
NPI:1437488921
Name:PURE JOY PEDIATRICS, P.C.
Entity Type:Organization
Organization Name:PURE JOY PEDIATRICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LA DONNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-421-9706
Mailing Address - Street 1:36880 WOODWARD AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-0919
Mailing Address - Country:US
Mailing Address - Phone:248-220-2384
Mailing Address - Fax:248-630-2627
Practice Address - Street 1:36880 WOODWARD AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-0919
Practice Address - Country:US
Practice Address - Phone:248-220-2384
Practice Address - Fax:248-630-2627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-14
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301088258208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1952509838Medicaid