Provider Demographics
NPI:1598242455
Name:GRATIOT ADVANCED CENTER LLC
Entity Type:Organization
Organization Name:GRATIOT ADVANCED CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAKEISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-924-8994
Mailing Address - Street 1:7612 GRATIOT AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48213-2822
Mailing Address - Country:US
Mailing Address - Phone:313-924-8994
Mailing Address - Fax:313-924-8990
Practice Address - Street 1:7612 GRATIOT AVE STE 200
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-2822
Practice Address - Country:US
Practice Address - Phone:313-924-8994
Practice Address - Fax:313-924-8990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-24
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty