Provider Demographics
NPI:1720104433
Name:SOUTHERN CHRISTIAN LEADERSHIP CONFERENCE
Entity Type:Organization
Organization Name:SOUTHERN CHRISTIAN LEADERSHIP CONFERENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAUD
Authorized Official - Middle Name:R
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:313-894-3950
Mailing Address - Street 1:8500 14TH ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48206-2425
Mailing Address - Country:US
Mailing Address - Phone:313-894-3950
Mailing Address - Fax:313-894-1729
Practice Address - Street 1:5050 JOY RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48204-2263
Practice Address - Country:US
Practice Address - Phone:313-894-3950
Practice Address - Fax:313-894-1729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0Q24522261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0Q24522Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER