Provider Demographics
NPI:1841061645
Name:MCCOY, LUELLAN
Entity type:Individual
Prefix:
First Name:LUELLAN
Middle Name:
Last Name:MCCOY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18301 E 8 MILE RD STE 213
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-3227
Mailing Address - Country:US
Mailing Address - Phone:313-790-0644
Mailing Address - Fax:
Practice Address - Street 1:18301 E 8 MILE RD STE 213
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-3227
Practice Address - Country:US
Practice Address - Phone:313-790-0644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI9107996OtherPROVIDER