Provider Demographics
NPI:1457107286
Name:GAMBLE, ALEX
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:GAMBLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 BALDWIN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48213-2427
Mailing Address - Country:US
Mailing Address - Phone:313-293-1122
Mailing Address - Fax:
Practice Address - Street 1:5700 BALDWIN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-2427
Practice Address - Country:US
Practice Address - Phone:313-293-1122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant