Provider Demographics
NPI:1891405031
Name:PURE HEALTH OF MICHIGAN
Entity Type:Organization
Organization Name:PURE HEALTH OF MICHIGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANTOINE
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-233-4076
Mailing Address - Street 1:17800 NORTHLAND PARK CT
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4304
Mailing Address - Country:US
Mailing Address - Phone:248-233-4076
Mailing Address - Fax:248-233-4079
Practice Address - Street 1:17800 NORTHLAND PARK CT
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4304
Practice Address - Country:US
Practice Address - Phone:248-233-4076
Practice Address - Fax:248-233-4079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-29
Last Update Date:2022-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty