Provider Demographics
NPI:1578195889
Name:MAVERICK ONE INC
Entity Type:Organization
Organization Name:MAVERICK ONE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAWANDA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-283-3722
Mailing Address - Street 1:900 LINCOLN LN APT 802
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2987
Mailing Address - Country:US
Mailing Address - Phone:313-283-3722
Mailing Address - Fax:
Practice Address - Street 1:900 LINCOLN LN APT 802
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2987
Practice Address - Country:US
Practice Address - Phone:313-283-3722
Practice Address - Fax:313-914-3094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health